Chapter 26: Cardiac Flashcards by Reio Kuo

What kind of shunts cause cyanosis?

Right to left shunts

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Why do children squat in right to left shunts?

To increase SVR and decrease right to left shunts

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R -> L shunts cause cyanosis. What can this lead to?

Polycythemia, strokes, brain abscess, endocarditis

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Shift from L -> R shunt to R -> L shunt

Eisenmenger’s syndrome

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What causes Eisenmenger’s syndrome?

Increasing pulmonary vascular resistance (PVR) and pulmonary HTN; this condition is generally irreversible

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What do left to right shunts cause?

CHF: manifests as failure to thrive, increased HR, tachypnea, hepatomegaly; CHF in children, hepatomegaly

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What is the first sign of a left to right shunt?

Hepatomegaly

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L -> R shunts (CHF)

VSD, ASD, PDA

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R -> L shunts (cyanosis)

tetralogy of Fallot

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Connection between descending aorta and left pulmonary artery (PA); blood shunted away from lungs in utero

Ductus arteriosus

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Connection between portal vein and IVC; blood shunted away from liver in utero

Ductus venosum

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Fetal circulation:

To placenta
From placenta

to placenta: 2 umbilical arteries

from placenta: 1 umbilical vein

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MC congenital heat defect

VSD (L -> R shunt)

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% of VSD that close spontaneously

80% (usually by age 6 months)

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Usually cause symptoms after 4-6 weeks of life, as PVR decrease, and shunt increased

Large VSDs (can get CHF - tachypnea, tachycardia - and failure to thrive)

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Medical treatment: VSD

Diuretics and digoxin

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Usually timing of repair:

Large VSDs (shunt > 2.5)
Medium VSDs (shunt 2-2.5)

Large: 1 year of age
Medium: 5 years of age

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Most common reason for earlier repair of VSD

Failure to thrive

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L->R shunt

Usually symptomatic when shunt > 2 -> CHF (SOB, recurrent infections)
Can get paradoxical emboli in adulthood
Medical tx: diuretics and digoxin

Atrial septal defect

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Most common (80%); centrally located ASD

Ostium secundum

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Can have mitral valve and tricuspid valve problems; frequent in Down’s syndrome

Ostium primum (or atrioventricular canal defects or endocardial cushion defects)

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Usual timing of repair ASD

1-2 years of age (age 3-6 months with canal defects)

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VSD
Pulmonic stenosis
Overriding aorta
RVH

Tetralogy of Fallot

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MC congenital heart defect that results in cyanosis

Tetralogy of Fallot

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Medical treatment: tetralogy of fallot

Beta-blocker

Usual timing of repair: tetralogy of fallot

3-6 months of age

Repair: tetralogy of fallot

RV outflow tract obstruction (RVOT) removal, RVOT enlargement, and VSD repair

L-> R shunt | - Requires surgical repair through left thoracotomy if it persists

Patent ductus arteriosus (PDA)

Causes PDA to close; rarely successful beyond neonatal period

Indomethacin

Most common cause of death in the United States

Coronary artery disease

Risk factors: coronary artery disease

Smoking, HTN, male gender, family history, hyperlipidemia, diabetes

Medical treatment: coronary artery disease

Nitrates, smoking cessation, weight loss, statin drugs, ASA

Branches of left main coronary artery branches

Left anterior descending (LAD) and circumflex (Cx) arteries

Location of most atherosclerotic lesions

Most atherosclerotic lesions are proximal

Complications of myocardial infarction

- VSR (ventricular septal rupture) | - Papillary muscle rupture

Hypotension, pansystolic murmur, usually occurs 3-7 days after MI; have a step-up in oxygen content between right atrium and pulmonary artery secondary to L->R shunt

VSR (ventricular septal rupture)

Why is there a step up in oxygen content in ventricular septal rupture?

Step-up in oxygen content between the right atrium and pulmonary artery secondary to L->R shunt.

Dx / Tx: ventricular septal rupture

Dx: echo Tx: IABP to temporize, patch over septum

Get severe mitral regurgitation with hypotension and pulmonary edema; usually occurs 3-7 days after MI

Papillary muscle rupture

Dx / Tx: papillary muscle rupture

Dx: echo Tx: IABP to temporize, replace valve

Restonosis rate in drug-eluting stent

Restenosis in 20% at 1 year

5 year potency of saphenous venous graft

80% 5-year patency

What is the internal mammary artery a branch of?

Subclavian artery

- Best conduit for CABG (>95% 20 year potency when placed to LAD) - Collateralizes with superior epigastric artery

Internal mammary artery

For CABG procedure: causes arrest of the heart in diastole; keeps the heart protected and still while grafts are placed

Potassium and cold solution cardioplegia

Best indications for CABG

- > 70% stenosis significant for most areas except left main disease. - Left main disease (> 50% stenosis considered significant - 3 vessel disease (LAD, Cx, and right coronary artery) - 2 vessel disease involving the LAD - Lesions not amenable to stenting

High mortality risk factors in coronary artery disease

Pre-op cardiogenic shock (#1 risk factor). Emergency operations. Age. Low EF.

Most common valve lesion, calcification produces stenosis

Aortic stenosis

What type of valve does not require anticoagulation?

Bioprosthetic tissue valves

When would you consider bioprosthetic tissue valves?

For patients who want pregnancy, have contraindication to anticoagulation, are older (>65) and unlikely to require another valve in their lifetime, or have frequent falls

How long does bioprosthetic tissue valve last?

Lasts 10-15 years -> not as durable as mechanical valves

Why are bioprosthetic tissue valves contraindicated in children and younger patients?

Because of rapid calcification in children and young patients, use of tissue valves is contraindicated in those populations.

Valvular lesion most from degenerative calcification

Aortic stenosis

Cardinal symptoms of aortic stenosis

- DOE: mean survival 5 years - Angina: mean survival 4 yrs - Syncope: mean survival 3 yrs

Worst of the cardinal symptoms of aortic stenosis

Syncope: mean survival is 3 years

Indications for operation in aortic stenosis

When symptomatic (usually have a peak gradient > 50 mmHg and a valve area

Valve disease causing dilation of the left ventricle

Mitral regurgitation (MR)

Key index of disease progression in patients with MR

Ventricular function

Arrhythmia common in mitral regurgitation

Atrial fibrillation: is common, in end-stage disease, pulmonary congestion occurs

Indications for operation in mitral regurgitation

When symptomatic or if severe mitral regurgitation

Rare now, most from rheumatic fever | - Get pulmonary edema and dyspnea

Mitral stenosis

Indication for operation in mitral stenosis

When symptomatic (usually have valve area

Often used as 1st procedure for mitral stenosis

Balloon commissurotomy to open valve often used as 1st procedure (not as invasive)

Symptoms of endocarditis

Fevers, chills, sweats

Most common site of prosthetic valve infections

Aortic valve endocarditis

Most common site of native valve infections

Mitral valve endocarditis

Responsible for 50% of cases of endocarditis

Staphylococcus aureus

Most common organisms causes endocarditis in drug abusers

Pseudomonas

Most common site of endocarditis in drug abusers

Left sided endocarditis

Initial treatment of endocarditis

Medical therapy first: successful in 75%, sterilizes valve in 50%

Indications for surgery in endocarditis

Failure of antimicrobial therapy, severe valve failure, perivalvular abscesses, pericarditis

Most common benign tumor of the heart

Myxoma; 75% in LA

Most common malignant tumor of the heart

Angiosarcoma

Most common metastatic tumor to the heart

Lung cancer

Tx: coming off cardiopulmonary bypass and aortic root vent, blood is dark and aortic perfusion cannula blood is red

Tx: ventilate the lungs

Have the lowest oxygen tension of any tissue in the body

Coronary veins: due to high oxygen extraction by myocardium

Swelling of the upper extremities and face | - Most cases secondary to lung CA invading the SVC

Superior vena cava (SVC) syndrome

Treatment of tumors causing SVC syndrome

These tumors are unresectable since the tumor has invaded the mediastinum. - Tx: emergent XRT

Mediastinal bleeding: when do you need to re-explore after cardiac procedure?

> 500 cc for 1st hour or > 250cc/hr for 4 hours

Risk factors for mediastinitis

Obesity, used of bilateral internal mammary arteries, diabetes

Tx: mediastinitis

Debridement with pectoralis flaps, can also use omentum

Pericardial friction rub, chest pain, SOB - EKG: diffuse ST-segment elevation in multiple leads Treatment?

Post-pericardiotomy syndrome TX: NSAIDS, steroids