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10: Cardiovascular System > Chapter 106 Cardiac Surgery > Flashcards

Chapter 106 Cardiac Surgery Flashcards

1
Q

VSDs classified according to anatomic location. What are classifications and which type is most common?

A

Muscular or membranous.

Membranous most common.

N.B. VSD = 12% canine congeital heart defect, one of most common in cats!

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2
Q

Closure of PDA may resut in a reflex - what is it called and what is the effect?

A

Branham reflex (suspected to be to do with cardiac baroreflexes)

Hypertension and bradycardia

Tx with glyco or atropine

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3
Q

List 8 reported cardicac neoplasia in dogs

A
  • Haemangiosarc
  • Chemodectoma
  • Ectopic thyroid
  • Finrosarcoma
  • Fibroma
  • Chondrosarcoma
  • Rhabdomyosarcoma
  • Myxoma

N.B. Not mesothelioma

In cats usually lymphoma or metastatic.

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4
Q

What is the recommended time limit for aortic cross clamp?

A

90 mins

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5
Q

What are surgical indications for ASD?

What surgical options?

A
  • Septal shunt flow velocity > 0.45 m/s (N.B musch lower value than eg pulmonic stenosis or VSD)

Sx:

  • Open repair (R atriotomy) with autogenous pericardium (N.B. sinus venosus defect (with abnormal pulmonary vein anatomy) needs careful planning to ensure ‘aberrant’ pulmonary vein drains into L atrium.
  • ACDO reported for ostium secundum defects.

AV block is a post-op risk (same with VSD repair)

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6
Q

What is the formula for Pulse pressure? And therefore what factors might influence pulse pressure

A

Pp = SV/CA (where CA = compliance of large elastic arteries)

Low SV of poor compliance –> low Pp

High PP can be due to diastolic run off e.g. with PDA or aortic insufficiency

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7
Q

In what breed is tricuspid dysplasia hereditary?

Surgical indication?

Sx options?

Anti-coagulation aims?

A
  • Labs
  • Severe tricuspid regurg = indication for sx
  • Tricuspid valve replacement
  • INR 2.0-3.0 (N.B. lower than mitral valve replacement which is 2.5-3.5)
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8
Q

What are surgical indications for mitral regurg?

And contraindication?

A
  • Diuretic dependedn CHF
  • Significant LV remodelling w activity intolerance
  • Progressive LA dilation
  • Chnages in systolic funtion over time

Contraindication: severe chronic inflammatory airway disease +- tracheal collapse.

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9
Q

Whats is MST for excision of cardiac haemangiosarc without chemo

A

4 months

N.B.Pericariectomy without tumour excision does not prolong survival!

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10
Q

What is the reported rate of major complications in epicardial and transvenous pacemaker placement?

A

25% major with epicardial (8% intraop mortality), 13% with transvenous

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11
Q

What is the difference between passive and active epicardial pacemaker fixation?

A

Passive = button liek ending applied to epicardium (what we have in QMH)

Active = screw-type end that penetrates myocardium.

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12
Q

List 3 ‘unusual’ findings in rverse (R –> L) PDA

A
  • Differential cyanosis
  • No murmur
  • Polycythemia
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13
Q

Where do the left and right recurrent laryngeal nerves originate (ie at what level, anatomically)?

A

Left recurrent laryngeal originates at level of ductuse arteriosum.

Right recurrent laryngeal originates at level of right subclavian (i.e. shorter)

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14
Q

List 4 surgical indications for DCRV

List 2 surgical techniques (and approaches). N.B. Sx palliative

A
  1. Pressure gradient >50 mmHg (n.b. less well tolerated that pulmonic stenosis. Sx indication for pulmonic stenosis is gradient >60 mmHg)
  2. Worsening tricuspid regurg
  3. Severe execise intolerance
  4. Syncope

N.B Refractory CHF and AF = poor surgical canidates.

Surgical techniques:

  1. Excision of fibromuscular tissue (via ventriculotomy (median sternotomy) or atriotomy (R 5th ICT))
  2. Patch graft across RVOT (median sternotomy or L ICT)
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15
Q

List parameters that are continuously and periodically monitored during bypass:

A

Continuously:

  • Arterial BP
  • Central venous pressure
  • Oesophageal and rectal temp
  • ECG
  • ET CO2

Periodically:

  • Blood gases (arterial and venous)
  • Na+, K+, ionized Ca2+
  • Lactate
  • HCT
  • TP
  • Activated clotting time (=tests intrinsic + common pathways. Contains beads that activate factor 10)
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16
Q

What species breeds get congenital mitral valve dysplasia?

What abnormalities can be seen?

A

Cats and large/giant breed dogs

  • Short thick leaflets
  • Cleft leaflets
  • Chordae malformations
  • Malpositioned papillary muscles

Mitral regug usually results from restrictive leaflet motion + secondary annular dilation.

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17
Q

How is inflow occlusion achieved?

A

Touriques around caudal vena cava, cranial vena cava and azygous vein (if approached from R ICT can ensnare Cr VC and azygous caudal to division).

Watch out for phrenic n.

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18
Q

When is differential cyanosis seen?

A

Reverse (R –> L) PDA.

i.e. de-oxygenated blood flowing out via pulmonary artery –> bypasses lungs via PDA –> descending aorta.

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19
Q

Label the diagram

A
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20
Q

What is anticoagulation aim after mitral valve replacement?

A

Duration based on valve type (life long if mechanical, 3 months if bioprosthetic).

Aim for INRof 2.5-3.5 (international normalised ratio, based on prothrombin time)

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21
Q

What are the major and minor criteria for diagnosis of infective endocarditis?

A

Major:

  • Positive blood culture of known causative agent at different time points
  • Characterisitc echo findings (i.e. vegetative lesion on valve

Minor:

  • Known predisposing heart conditions
  • Persistent fever
  • Arterial embolic events
  • Immune complex conditions
  • Positive serology for known causative agents e.g. Bartonella
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22
Q

What is surgical mortality rate?

Factor associated with increased risk post-op mortality?

Factors associated with increased risk of rupture (most common cause of operative mortality)?

A

Surgical mortality: 0-7%

Assoc w post-op mortality: CHF

Assoc w rupture: less surgeon experience, older animal

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23
Q

List 5 breeds at risk for aortic stenosis

A

Large breed: Golden retriever, Boxer, Rottweiler, Newfoundland, Bull Terrier, Bouvier

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24
Q

List following post-bypass recovery targets:

  • CVP
  • HCT
A
  • CVP: 4-10 mm Hg
  • HCT >30%
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25
Q

What is a normal volume of pericardial fuid in the dog?

A

0.5-1.0ml total

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26
Q

Before cannulation and initiation of bypass, patient must undergo anti-coagulation. What dose is recommended. What test is used to measure efficacy + what is target value?

A

300-400 U/kg heparin iv

ACT to monitor, aim for ACT >480s

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27
Q

When is PDA closure contra-indicated?

A

R –> L shunt or bidirectional shunt

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28
Q

Which species get cor triatriatum dexter and which sinister?

Breed predilection?

A

Dogs = dexter. Chow chows

Cats = sinister

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29
Q

Pulmonic stenosis is usually valvular (can be supra or sub-valvular also). More than 80% of dogs w valvular stenosis have some degree of valve dysplasia. Based on valve anatomy, valvular pulmonic stenosis is classified into two groups - what are they?

A

Type A valvular pulmonic stenosis: Normal annulus diameter (aortic:pulmonary ratio ≤1.2)

Type B valvular pulmonic stenosis: Hypoplastic annulus diameter (aortic:pulmonary ratio ≥1.2)

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30
Q

List the three classifications of ASD (which most common?)

A
  • Ostium Secundum - located in the center of the atrial septum (most common type)
  • Coronary Sinus - incomplete separation between coronary sinus and left atrium.
  • Sinus Venosus - located near top of atrial septum/juntion with cava. Frequently associated with abnormal connection of the right pulmonary vein(s) to the right atrium instead to the left atrium
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31
Q

List two methods for venous cannulation during bypass:

A
  • Bi-caval (if right thoracotomy!)
  • Cavoatrial (can be performed via right or left thoracotomy. Via R auricular appendage - one port directed into CVC other into atrium)
  • Jugular (if left thoracotom i..e cant do bicaval..)
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32
Q

Between which intercostal spaces is heart located?

A

3-6

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33
Q

What is the only predictor of survival in cases with aortic stenosis?

A

Severity of pressure gradient at diagnosis.

i.e. surgery, balloon valvuloplasty, medical tx with beta-blockers do not affect survival.

Life expectancy 4-6 years.

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34
Q

What surgical treatment options exist for aortic regurg?

A

Heterotopic (=out of usual place) aortic valve implantation (porcine bioprosthetic). I.e. valve implantation by end to end anastomosis of descending aorta!

Performed by vascular occlusion of descending aorta (keep to <13 mins - risk of spinal cord injury)

Only single canine case report re outcome - lived for 5+ years

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35
Q

What treatment can be considered for aortic body tumours?

A

Pericardiectomy. Prolongs survival, regardless whether effusion present or not

700d vs 42d!

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36
Q

How many papillary muscles does th eleft ventricle have?

A

Two (each receives chordae from each leaflet i..e one papillary muscle attaches to both valve leaflets)

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37
Q

What four abnormalities constitute tetralogy of fallot?

A
  • VSD
  • Pulmonic stenosis
  • Overriding aorta
  • R V hypertrophy

Pathophys can vary from ‘haemodynamically restirtive’ –> balanced (analagous to VSD after pulmonary banding) –> severe stenosis and R –> L shunting

38
Q

Mitral valve anatomy:

Two valve leaflets septal (anterior) and mural (posterior/parietal).

Each leaflet structurally divided into three distinct portions; A1, A2 and A3, and P1, P2 and P3.

There are three orders of chordae tendinae. How are they defined?

A

Primary: Leaflet edge –> Papillary muscle

Secondary: Leaflet underside –> Papillary muscle

Tertiary: Leaflet underside –> Ventricular wall

39
Q

How many vale leaflets does each heart valve have?

A

Tricuspid: Two

Pulmonary: Thee (semi-lunar)

Mitral: Two

Aortic: Three (semi-lunar)

40
Q

What proportion of cardicac tumours are haemangiosarcomas?

What % of splenic haemangiosarcs have cardiac neoplasia?

What % of cardiac endothelial tumour have splenic haemangiosarc?

A

40-70%

9% (golden ret x10 more likely to have ecardiac involvement vs other breeds)

30%

41
Q

What is the most important cause of aortic regurg?

A

Infective endocarditis

(less frequently due to degenerative valve changes, annulus dilation, or associated with congenital defects (VSD, subvalvular stenosis)

42
Q

At what body temperature is effective cardiac rhythm re-established?

A

37º

43
Q

List two options (vessels) for arterial cannulation.

A

Femoral artery or carotid artery

(size 8 - 14 Fr cannulae used)

44
Q

What approach provides best acces to cranial and caudal cava, azygous vein and R atrium?

A

R intercostal

45
Q

What is the significance of the interventricular grooves?

A

Represent the path of coronary arteries

(Called sinusoidal and paraconal)

46
Q

List 2 advantages and 3 disadvantages of mitral valve replacement (bileaflet tilting disc or bioprosthetic)

A

Advantages:

  • Easier to perform
  • Complete correction of regurg.

Disadvantages:

  • Patient BW has to be >10kg re size of valve.
  • Thrombogenic (lifelong anticoag in mechanical valve (56% catastrophic thrombosis despite warfarin), 3 months in bioprosthetic)
  • Inflammatory pannus (bioproshtetic)
47
Q

What is Eisenmenger syndrome?

A

VSD + R –> L shunting due to pulmonary hypertension

48
Q

List 2 advantages of inflow occlusion vs bypass

List 3 disadvantages:

A

Advantages:

  1. Less equipment/complexity
  2. Fewer CVS metabolic, haematological derangements

Disadvantages:

  1. Limited time
  2. Motion
  3. Lack of fall back if procedure taking longer
49
Q

List 3 broad options for management of PDA

A
  • Surgical ligation
  • Amplatz Canine Ductal Occluder (ACDO) (=nitinol wire mesh. Generally need 5 Fr catheter in artery)
  • Coil embolization (trans-arterial or transvenous reported - venous allows bigger size)
50
Q

In which order do ion channels open in generation of cardical action potential?

Which ion initiates contraction of cardiomyocyte?

A
  1. Na2+
  2. K
  3. Ca2+

Ca2+ entry into cell –> contraction

51
Q

what % congenital heart defect does pulmonic stenosis account for?

List 2 breedsthat commonly present with type B (hypoplastic annulus) pulmonic stenosis

A

20% of congenital heart defects i.e common

English Bulldog and Boxer N.B. also breeds that at risk for anomalous left coronary (L coronary originates from single R coronary ostium meanign L coronary courses around R VOT… implications re ballooning

52
Q

List 3 techniques to manage intra-op PDA rupture

A
  • Jackson Henderson technique (i.e. dissect DV path from ventral to dorsal aorta. do this cranially and caudally to PDA and pass suture between so that ultimate suture lies behind PDA, without having to dissect directly behind ductus.
  • Buttressed mattress sutures
  • Divide and over-sew
53
Q

How is severity classified for aortic stenosis?

Why is it relevant?

A

Mild: pressure gradient 16-50 mmHg

Moderate: pressure gradient 50-80 mmHg

Severe: pressure gradient >80 mmHg

Relevant because this is the only factor associated with outcome (i.e. not affected by surgery or balloon valvuloplasty)

54
Q

Surgical options for cortriatriatum?

A

Membranectomy (open or via intravascular/hybrid)

55
Q

How is coronary dominance determined?

What is the usual coronary dominance in dogs? And in cats?

A

Indicated which coronary artery supplies the subsinusoidal interventricular groove.

Dogs usually left coronary dominance, cats usually right coronary dominance.

56
Q

What is the desired HCT during bypass?

A

25-28%

(oxygen delivery and whole body oxygen uptake decrease when HCT <18%)

57
Q

PDA is most common congenital heart defect - what % of congenital malformations does it account for?

A

25-30%

58
Q

What is administered to reverse heparin, what dose/target, what are the side effects?

A

Protamine sulfate

5 mg/min until ACT <150s

S/e: hypotension, pulmonary vasoconstriction.

59
Q

Label the diagram

A
60
Q

List 4 indications for surgical intervention for pulmonic stenosis.

List 3 “treatment” techniques

Aim of treatment?

A

Indications for surgery:

  1. Presence of tricuspid regurgitation
  2. Severe stenosis
  3. >60 mmHg pressure gradient across defect
  4. Clinical signs present

Treatment techniques:

  1. Balloon dilation valvuloplasty (intravascular/hybrid - nb coronary artery anatomy/rupture risk. Tx of choice for Type A. <10% mortality)
  2. Surgical pulmonic dilation valvuloplasty (inflow or CPB, commissurotomy or excision. Doesnt address infundibular hypertrophy/annulus hypoplasia - useful for anaomalous L coronary cases.)
  3. Open pulmonic patch graft valvuloplasty (Autogenous pericardium or PTFE path. Inflow (L 5th ICT - to tourniquet Cd Cava) vs CPB (median sternotomy). 30% mortality rate. CONTRAINDICATED if anomalous L coronary!)

Aim:

Pressure gradient <50 mmHg

61
Q

Label diagram of bypass circuit (i.e. heart-lung machine + bypass circuit)

A

Heart-lung machine: Pumps, heater/cooler, oxygenator, gas flowmeter, anaesthetic vapourizer.

Bypass circuit: Resevoir, pump, membrane oxygenator, heat exchanger, heater/cooler water bath

62
Q

List three interventios for management of VSD

A
  • Pulmonary artery banding: usually 2/3rds reduction in vessel diameter, measure pressure distal to band, ideally <30 mmHg. Palliative. Complication = overtightening + flow reversal
  • Open repair: (CPB, access via R atrium or R ventricle) with PTFE or Dacron graft - care re caudal margin as major conduction bundles located there.
  • Intravascular/hybrid: ACDO reported for muscular VSD
63
Q

Physiologically speaking, how does AV node slow action potential?

A

AV node cells lack voltage dependednt Na2+ channels (i.e. fast channels)

64
Q

What are the three most common congenital heart defects in dogs?

A

PDA, pulmonic stenosis, aortic stenosis

65
Q

Double chambered R ventricle –> inflow obstruction of R ventricle. What is proposed mechanism of formation? N.B. in humans usually associated with another abnormality and same suspected in dogs

A

Often associated with VSD.

Mechanism suspected = dorsal displacement of moderator band + turbulent flow from VSD (VSD closes) –> hypertrophic obstructive area mid ventricle

66
Q

Body temp should not be allowed to fall below 32º during inflow occlusion. Why?

A

Increased risk of ventricular fibrillation

67
Q

Particular clinical signs in cor triatriatum dexter and why?

A

Ascites, venous distensionin caudal half of body.

Because membrane forms between caudal vena cava and tricuspid valve, i.e. flow from cranial cava unaffected.

68
Q

What are surgical indications for Tetralogy of Fallot?

Surgical options?

A

Indications:

  • Debilitating exercise intolerance
  • Polycythemia (HCT >70%)
  • Resting hypoxaemia

Options:

  • Isolated correction of pulmonic stenosis
  • Creation of sytemic to pulmonary shunt i.e. aorta/subclavian –> pulmonary artery. e.g. Blalock-Taussig
  • Open repair (bypass inc VSD closure and pulmonic patch graft). Curative
69
Q

What is the most common location of pulmonic vs aotic stenosis (sub-, supra-, or valvular)?

A

Pulmonic stenosis usually valvular, aortic stenosis usually subvalvular

70
Q

Outflow portions run parallel to each other. At what anatomical level does separation occur?

A

At the level of the septal mitral valve leaflet (specifically called mitral curtain)

71
Q

What is the time limit for planned circulatory arrest (i.e. inflow occlusion) in normothermic patient?

And in hypothermic patient:

A

Normothermic: <2 min

Hypothermic (32-34º): <4 mins

72
Q

What is the ventricular conducting system called?

A

His-Purkinje conduction system

73
Q

What does Waterston’s groove represent?

A

The embryologic separation between the right and left atria.

74
Q

List key steps in mitral valve replacement

A
  • ICT
  • L atriotomy
  • Septal leflet excised (not mural to preseve myocardial function)
  • Pre-place buttressed sutures through annulus.
  • Place sutures through sewing ring of replacement.
75
Q

What three variables determine SV?

A

Preload, afterload and contractility

Preload: mean filling pressure (i.e. blood volume and venous vascular tone) and vascular resistance i.e. determinants of pre-load are outside the heart.

Afterload: Systolic wall stress. Predicted by LaPlace relationship (/formula)

SWS = (Psys x ventricular radius)/ventricular wall thickness

i.e. beat-to-beat afterload determined by systolic pressure. On chronic basis, cardiac remodelling affects afterload.

Contractility: Largely a function of amoiunt of sympathetic (ß) influence on heart.

76
Q

What anatomic reference point indicates level of phrenic nerves?

A

Coronary groove

77
Q

Where does the azygous vein drain into?

A

The cranial cava (close to junction w right atrium)

78
Q

How is the left atrium approached?

A

L or right intercostal

79
Q

List values for the following bypass targets:

  • Body temperature
  • Venous oxygen saturation
  • MAP
  • PaO2
A
  • Body temperature: 25-28º (if >10kg), 15-18º (if <10kg)
  • Venous oxygen saturation: >70%
  • MAP: 50-70 mm Hg
  • PaO2: >120 mm Hg
80
Q

How is the RIGHT VOT (ventricular outflow tract) accessed?

A

L ICT or median sternotomy

81
Q

In what two breeds has heritable basis for PDA been established?

Sex prediclection?

A

Poodles and Welsh Corgis

Females

Also commoon in Keeshond, Bichon, Maltese, Yorkie, Cocker, Pom, Sheltie,

82
Q

What are the pressures in each cardiac chamber?

A
83
Q

List 3 surgical techniques for management of mitral valve leaflet prolapse

A
  • Quadratic resection –> mattress plication (cannot be used on septal leaf)
  • Edge to edge repair –> suture free edge of prolapsing leaflet to free edge of opposing leaflet –> double orifice valve.
  • Artificial chordae
84
Q

Which portionof annulus is corrected durign mitral valve annuloplasty.

A

Mural only. Principle is that the ural, but not septal, portion of annulus stretches.

Use annuloplasty ring or CV graft materials (Dacron or PTFE).

85
Q

Which congenital heart defect has been shown to pre-dispose dogs to bacterial endocarditis?

A

Aortic stenosis

86
Q

How is cardioplegia administered and what is it made of?

A

Cross clap aorta and cannulate aortic root + instill cardioplegia (i.e. runs into coronary arteries).

Cardioplegia = KCl + NaHCO3- + heparinized blood + crystalloid.

High [K+] –> arrest electrical and mechanical activity of myocardium.

87
Q

List two factors that affect vascular resistance (R)

A

Degree of vasoconstriction and blood viscosity

88
Q

What are the echo findings in DCRV?

A

Hypertrophy of R ventricle with abrubt transition to normal appearing RVOT distal to obstruction (only causes R ventricular inflow obstriution)

89
Q

What are the criteria for haemodynamically restrictive VSD (i.e. amount of blood flow via vsd is restricted so good prognosis without surgery).

What are criteria for surgery?

A

Heamodynamically restrictive:

  • High velocity shunt (>4.5 m/s)
  • Normal pulmonic ejection velocity (<2 m/s)

Large defects usually have low shunt velocity (<3.5 m/s) and higher pulmonic ejection velocity (>2.5 m/s)

Surgery:

  • High flow shunts

(aside from echo high flow shunts may also be indicated by radiographic pulmonary vascular enlargement, L ventricular (and ?atrial) enlargement)

90
Q

List 3 indications for epicardial (vs transvenous) pacemaker necessary.

A
  • Small patient size
  • Infection
  • Thromboemblic conditions
91
Q

When is pacemaker traetment indicated?

A
  • High grade 2nd degree, or 3rd degree AV block
  • Sick sinus syndrome
  • Sinus arrest
  • Other chronic bradyarrythmias
  • (Lack of response to medical treatment)
92
Q

How are epicardial pace markers affixed?

A

Passive (epicardial suture) or active (screw type)

(secured to left ventricle - avoid coronaries, close pericardium (better pacemaker contact - secure pulse generator in intermuscular pocket (under external oblique if exited via thorax (i.e. ICT approach), or under transverse abdominis is exited via diaphragm (i..e coeliotomy approach))

10: Cardiovascular System (3 decks)

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