Chapter 6: Cardiothoracic Surgery Flashcards
What types of symptoms do vascular rings produce?
Symptoms of pressure on the tracheobronchial tree and pressure on the esophagus.
What are some of the first symptoms of vascular rings?
- Stridor
2. Episodes of respiratory distress with “crowing” respiration during which the baby assumes a hyperextended position
What are some of the latter symptoms of vascular rings?
The latter revolve around some difficulty swallowing
What if only the respiratory symptoms occur, is it vascular rings?
No, one should think of tracheomalacia
What does a barium swallow show with vascular rings?
Shows typical extrinsic compression from the abnormal vessel
What does bronchoscopy show with vascular rings?
Segmental tracheal compression and rules out diffuse tracheomalacia.
What does the surgery do for babies with vascular rings?
Divides the smaller of the 2 aortic arches.
What is the best way to diagnose morphologic cardiac anomalies (congenital or acquired)
Echocardiogram
What do all Left to Right shunts have in common?
- Presence of a murmur
- Overloading of the pulmonary circulation
- Long-term damage to the pulmonary vasculature
Describe the pressure and volume of a Atrial septal defect
Very minor, Low pressure, low volume shunt
What is the characteristic sound of an atrial septal defect?
- A soft mid systolic murmur along the upper sternal border
2. wide, fixed split second heart sound
What is diagnostic for an ASD?
Echocardiogram
How can an ASD be corrected?
Closure can be achieved surgically or by cardiac cauterization
What type of VSD produces a slight murmur but with few other symptoms?
Small, restrictive VSD low in the muscular septum produce a heart murmur, but otherwise few symptoms
How can a small, restrictive VSD be corrected?
Likely to close spontaneously within the first 2 or 3 years of life
Where are VSD typically located?
High in the membranous septum
When does a VSD present?
Trouble early on.
Within the first few months there will be “failure to thrive”
What does a VSD murmur sound like?
A loud pansystolic murmur best heard at the left sternal boarder and increased pulmonary vascular markings on chest X-ray
What are some complications that may occur with Left to Right shunts?
- Pulmonary hypertension
- Right ventricular hypertrophy due to the pulmonary hypertension
- Left ventricular hypertrophy due to more blood returning to the L heart than normal
Why does Right ventricular hypertrophy occur in a L–> R shunt?
Pulmonary hypertension increases the AFTERLOAD the R. ventricle must contract against to eject blood, which causes CONCENTRIC hypertrophy of the R. ventricle.
Why does Left ventricular hypertrophy occur in a L–> R shunt?
Increases Left ventricle volume (preload) and produces an eccentric type of L. ventricular hypertrophy
What is there a danger of occurring in a L–> R shunt if it goes uncorrected?
Eisenmenger syndrome. Reversal of the hunt because the pressure in the right side of the heart is greater than the pressure in the left.
Signs= cyanosis and clubbing of fingers
What is the most common congenital heart defect?
VSD
What other diseases are associated with the presence of a VSD?
- Cri du chat syndrome
2. Fetal alcohol syndrome
What are the next steps for a VSD?
Do an echocardiogram and surgical closure. 50% spontaneously close.
Most common ASD?
Patent foramen ovalue (secundum type)
ASD is associated with what other conditions?
- Fetal Alcohol Syndrome
2. Down syndrome (primum type)
What is a paradoxical embolus and what is it associated with?
Is a venous clot material in the systemic circulation and associated with ASD
When do Patent ductus arterioles become symptomatic?
Symptomatic in the first few days of life.
What does a PDA sound like?
- Bounding peripheral pulses
2. Continuous machine-like murmur
What is diagnostic for a PDA?
Echocardiogram
When can a PDA be closed with a medication and what is that medication?
In premature infants who have not gone into congestive heart failure, closure can be achieved with indomethacin
When do babies with a PDA need surgery?
- babies who do not close
- Babies who are already in failure
- Full term babies
Need surgical division or radiological embolization with metal coils
What is differential cyanosis?
Child has a pink upper body and a cyanotic lower body due to a reversal of shunt in PDA
What does indomethatcin do?
Inhibits prostaglandin E2, a vasodialator
How are all the Right to left shunts similar?
- Presence of a murmur
- Diminished vascular markings
- Cyanosis
What is the most common cyanotic anomaly?
Tetralogy of Fallot
What are some of the characteristics of Tetraology of Fallot?
Children are small for their age, have a bluish hue in the lips and tips of their fingers, clubbing and spells of cyanosis relieved by squatting.
What does the murmur sound like for Tetralogy of Fallot?
- Systolic ejection murmur in the left third intercostal space (crescendo/deccrescendo) results in RV outflow tract obstruction
- small heart
- diminished pulmonary vascular markings on chest xray
- EKG show signs of RVH
What is diagnostic for Tetralogy of Fallot?
Echocardiogram, surgrical repair is done
How are kids with transposition of the great vessels kept alive?
The kids are kept alive by an ASD, VSD or PDA. but die very soon if not corrected
When is a transposition diagnosed?
1 or 2 day old child with cyanosis who is in deep trouble, ask for echocardiogram
What are the chances a coin lesion found on chest X-ray is malignant in people over 50?
80% and even higher if there is a history of smoking.
If a coin lesion is found what is the first step that should be done when trying to determine if it is malignant?
Finding an older ( a year or two) chest X-ray shows the same unchanged lesion then it is not cancer.
If you suspect lung cancer what is the first steps to diagnosis?
- Chest xray ( which may have been order because of persistent cough or hemoptysis)
What are two noninvasive tests that should be done if you have suspected cancer of the lung?
- sputum cytology
2. CT scan (including chest and liver)
What does diagnosis of cancer of the lung REQUIRE?
- bronchoscopy
- biopsies (for central lesions)
- percutanous biopsy (for peripheral lesions)
What if the biopsies for lung cancer are unsuccessful in diagnosing lung cancer?
Video assisted thoracic surgery (VATS) and wedge resection may be needed.
When do you really do VATS and wedge resection?
- the probability of cancer
- the assurance that surgery can be done (residual pulmonary function will suffice)
- the chance that the surgery may be curative (no mets)
How is small cell cancer of the lung treated?
With chemotherapy and radiation
NO SURGERY
What type of lung cancer is operable?
Non small cell cancer
How is operability of lung cancer predicted?
Residual function after resection
What type of surgery do you need for a central lesion?
Pneumonectomy
What type of surgery do you need for a peripheral lesion?
Removed with lobectomy
What is the minimum FEV1 for operability of lung cancer?
800 mL is needed.
What do you need to determine for operability of lung cancer?
- Determine FEV1
- Determine fraction that comes from each lung (by ventilation perfusion scan)
- Figure out what would remain after pneumonectomy
What happens if FEV1 is less than necessary?
Stop expensive test, Patient is not a surgical candidate and treat with chemotherapy and radiation.
What does the potential cure by surgical removal of lung cancer depend on?
Extent of mets.
How are hilar metastases treated?
Can be removed with the pneumonectomy
How are nodal metastases at the carina or medistinum treated?
They preclude curative resection.
What types of scans identify nodal metastasis?
CT scan and PET
What is a more invasive way to sample mediastinal nodes?
Endobronchial ultrasound
What are some physical symptoms of Aortic stenosis?
Produces angina
Exertional syncopal episodes
What does an aortic stenosis murmur sound like?
Harsh mid systolic heart murmur best heard at the right second intercostal space and along the left sternal border.
How do you start workup with aortic stenosis?
Echocardiogram.
When is surgical valvular replacement indicated in aortic stenosis?
If there is a gradient of more than 50 mmHg or at the first indication of congestive heart failure, angina or syncope.
How does chronic aortic insufficiency present?
Produces wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best hearts at the second intercostal space and along the left lower sternal border with the patient in full expiration.
When should valvular replacement occur for people with chronic aortic insufficiency?
at the first evidence on echocardiogram of beginning left ventricular dilation.
When is acute aortic insufficiency seen?
Because of endocarditis, seen in young drug addicts who suddenly develop congestive heart failure and a new loud diastolic murmur at the right second intercostal space
What is the treatment for acute aortic insufficiency?
Emergency valve replacement and long term antibiotics are needed.
Why do patients with prosthetic valves need antibiotic prophylaxis?
For subacute bacterial endocarditis.
What is mitral stenosis caused by years before presentation?
Rheumatic fever
What are the symptoms of mitral stenosis?
- Dyspnea on exertion
- Orthopena
- Paroxysmal nocturnal dyspnea
- Cough
- Hemoptysis
What is the murmur associated with mitral stenosis?
Low-pitched rumbling diastolic apical heart murmur
What happens when mitral stenosis progresses?
Patients become thin and cachetctic and develop A. Fib.
