Chapter 6: Cardiothoracic Surgery

Question 1

Vascular rings sx?

Answer 1

1. pressure on tracheobronchial tree and pressure on the esophagus
   Tracheobronchial Tree Pressure
   a. stridor
   b. respiratory distress, “crowing” respiration especially when baby assumes hyperextended position

Esophageal problems:
a. difficulty swallowing (if only respiratory sx are present then dx is likely tracheomalacia

Question 2

Vascular rings dx:

Answer 2

1. barium swallow: see typical extrinsic compression from abnormal vessel
2. bronchoscopy: segmental tracheal compression r/o tracheomalacia
3. surgery divides the smaller of the two aortic arches

Question 3

Best way to diagnose morphologic cardiac anomalies?

Answer 3

echocardiogram

Question 4

Atrial Septal Defect Sx and Dx?

Answer 4

1. very minor: low pressure, low volume shunt
2. may not be recognized until late infancy
3. history of frequent colds
4. pulmonary systolic flow murmur + fixed, split 2nd heart sound
   Dx: echocardiogram

Question 5

Atrial Septal Defect Tx:

Answer 5

1. surgical or cardiac catheterization

Question 6

Small, restrictive ventricular septal defect in muscular septum?

Answer 6

1. heart murmur
2. no other real sx
3. likely to close spontaneously in first 2-3 yrs

Question 7

VSDs

Answer 7

1. high in membraneous septum
2. “failure to thrive” in first few mths
3. loud pansystolic murmur heard in left sternal border
4. increasing pulmonary vasculature markings on chest X-ray
   Tx: do echo and surgical closure

Question 8

Patent ductus arteriosus:

Answer 8

1. sx in first few days of life
2. bounding peripheral pulses
3. continous “machine-like” heart murmur
4. echo is diagnostic
   Tx: indomethacin in premies who haven’t undergone CHF
   -those in CHF or full-term babies: do surgical division or embolization with coils

Question 9

Right-to-left shuts common sx?

Answer 9

1. murmur
2. diminished vascular markings in lungs
3. cyanosis

Question 10

Tetralogy of Fallot

Answer 10

1. kids can grow up into infancy
2. Most common cyanotic anomaly!!
3. kids are small for their age
4. bluish hue to lips and tips of finger
5. clubbing
6. spells of cyanosis relieved by squatting
7. systolic ejection murmur in left 3rd intercostal
8. small heart
9. right ventricular hypertrophy on EKG

Question 11

Transposition of great vessels:

Answer 11

1. need ASD, VSD, or PDA to stay alive
2. most common in 1-2 yo with cyanosis who is looking really poor
3. ask for echocardiogram

Question 12

Aortic Stenosis sx:

Answer 12

1. angina
2. exertional syncopal episodes
3. harsh mid systolic heart murmur

Question 13

When do you need a valve replacement in aortic stenosis?

Answer 13

1. if gradient of 50 mmHG or more
2. angina
3. syncope
4. heart failure

Question 14

Chronic aortic insufficiency sx:

Answer 14

1. wide pulse pressure

2. blowing, high-pitched, diastolic murmur best heard in 2nd intercostal space, with patient in full expiration

Question 15

Tx of chronic aortic insufficiency?

Answer 15

1. follow with medical therapy for many years

2. undergo valvular replacement at first evidence of left ventricular dilation on echo

Question 16

Acute aortic insufficiency:

Answer 16

1. 2ndary to endocarditis in young drug addicts
2. suddent CHF
3. new, loud diastolic murmur at right second intercostal space
   Tx; emergency valve replacement and long-term abx

Question 17

Mitral stenosis:

Answer 17

1. history of rheumatic fever many years before presentation
2. dyspnea on exertion
3. orthopnea
4. paroxysmal nocturnal dyspnea
5. cough
6. hemoptysis
7. low-rumbling diastolic apical heart murmur
   8 later-> thin, cachectic + afib

Question 18

Surgical treatment of mitral stenosis?

Answer 18

1. surgical commissurotomy

2. balloon valvuloplasty

Question 19

Mitral regurgitation:

Answer 19

1. valvular prolapse most common cause
2. exertional dyspnea
3. dyspnea
4. orthopnea
5. afib
6. Apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back

Question 20

Mitral regurg Tx:

Answer 20

annuloplasty ispreferred to prosthetic replacement

Question 21

Coronary disease indications for intervention:

Answer 21

70% or more stenosis in one or more vessel and there’s a good distal vessel

• prefer that pt has good ventricular function
• simple problems can be done via angioplasty and stent but more complex ones require surgery

Question 22

Post-op care of heart surgery:

Answer 22

1. often requires that cardiac output be optimized
2. If CO is significantly under 5L/min or cardiac index of 3–> pulmonary wedge pressure or left atrial pressure should be measured
   a. low value= 0-3 suggests need for more IV fluids
   b. high value= 20 or more–> ventricular failure

Question 23

Chronic constrictive pericarditis sx?

Answer 23

1. dyspnea on exertion
2. hepatomegaly
3. ascites
4. ‘square root sign’
5. equalization of pressures (right atrial, right ventricular diastolic, pulmonary artery diastolic, pulmonary capillary wedge, left ventricular diastolic)

Question 24

Likelihood of a coin lesion on x-ray to be malignant?

Answer 24

a. 80% chance in people over 50 and higher if there’s a history of smoking
b. look at an old chest x-ray for an unchanged lesion (FIRST thing you do)

Question 25

Workup for suspected cancer of lung?

Answer 25

1. double check that it’s new (look at old cxray)
2. sputum cytology
3. CT scan (chest and liver)

Question 26

Diagnosis of lung cancer?

Answer 26

1. cytology
2. bronchoscopy and biopsies (for central lesions)
3. percutaneous biopsy (for peripheral lesions0
4. Video-assisted thoracic surgery (VATS) and wedge resection needed if those are unsuccessful

Question 27

Do you do surgery on small cell cancer of the lung?

Answer 27

NO

only treat with chemotherapy and radiation

Question 28

What things determine how aggressively you diagnose and treat a non-small cell cancer?

Answer 28

1. the likelihood of cancer: age, history of smoking, non calcified lesion on CT
2. assurance that surgery can be done (residual pulmonary function will suffice)
3. the chances that surgery will be curative (no mets to the mediastinal or carinal nodes, other lung, or liver)

Question 29

What type of lung cancers require pneumonectomy vs lobectomy?

Answer 29

pneumonectomy: central lesion
lobectomy: peripheral lesion

Question 30

What minimum FEV1 is required to maintain functional lung capacity after lung resection for cancer?

Answer 30

800 mL (determine using PFTs and ventilation-perfusion scan)

Question 31

Can you remove hilar metastases with pneumonectomy?

Answer 31

yes

Question 32

Can you remove nodal metastases at the carina or mediastinum?

Answer 32

no!

…resection wouldn’t be curative…

Question 33

How to detect nodal or carinal metastases?

Answer 33

CT scan  (also shows mets to lung or liver)
PET scan (can identify actively growing tumor in enlarged nodes) 
Endobronchial ultrasound to sample mediastinal nodes 
Cervical mediastinal exploration is rarely needed