CT surgery

Question 1

What artery is most often used in CABG?

Answer 1

Internal mammary artery, usu to LAD

Question 2

How does intra-aortic balloon pump work?

Answer 2

Inflates during diastole to increase coronary artery flow. Deflates during systolic to create negative pressure, decreasing afterload.

Question 3

What valvular disease may cause hoarse voice?

Answer 3

Mitral stenosis -> left atrial dilation and impingement on recurrent laryngeal nerve

Question 4

Nonsurgical choices for mitral stenosis?

Answer 4

Endocarditis ppx, tx for heart failure, tx afib if present. Balloon valvuloplasty works pretty well (unlike for aortic stenosis)

Question 5

Surgical choices for mitral stenosis

Answer 5

Open commissurotomy: incise fused leaflets, debride calcification etc. Valve replacement: if too much debridement would be required. Minimally invasive MV surgery (port access).

Question 6

Causes of mitral insufficiency (MR)

Answer 6

Papillary muscle dsyfunction (ischemia, infarction), rupture of chordae tendinae, damage to valve from rheumatic dz or post-endocarditis, prolapse that has progressed to incompetence.

Question 7

Why is there a widely split S2 in cases of severe MR?

Answer 7

Premature emptying of LV

Question 8

Why is there paradoxical splitting of S2 in aortic stenosis?

Answer 8

Delayed emptying of the LV

Question 9

Indications for aortic stenosis surgery (valve replacement)

Answer 9

Any symptoms; no symptoms with high transvalvular gradient and LVH or declining LVEF; valve area

Question 10

Causes of aortic regurgitation

Answer 10

Aortic root dilation: idiopathic (e.g. HTN and age), Marfan, collagen vascular disease. Valvular: rheumatic heart disease, endocarditis. Proximal aortic root dissection: cystic medial necrosis, syphilis, HTN, Ehlers-Danlos, Turner syndrome, third trimester.

Question 11

What’s the deal with cystic medial necrosis of the aorta?

Answer 11

Familial thoracic aortic aneurysm (also referred to as familial aortic dissection or cystic medial necrosis of aorta) is an autosomal dominant disorder of large arteries.
Assoc with Marfan syndrome, massive baclofen overdose, and other hereditary connective tissue disorders. A degenerative breakdown of collagen, elastin, and smooth muscle caused by aging -> weakening of aortic wall.

Question 12

Causes of tricuspid stenosis

Answer 12

Rheumatic heart disease, congenital, carcinoid tumor associated

Question 13

How to tell tricuspid stenosis murmur from mitral stenosis murmur?

Answer 13

Both are rumbling diastolic murmurs, however tricuspid murmur will increase with inspiration

Question 14

Causes of tricuspid regurgitation

Answer 14

Increased PAP (e.g. left-sided failure or mitral regurg/stenosis). RV dilation. Right papillary muscle rupture (infarction). Tricuspid valvular lesions (rheumatic heart disease, endocarditis).

Question 15

Murmur of tricuspid regurgitation

Answer 15

Holosystolic, blowing murmur accentuated with inspiration

Question 16

What is a common complication of tricuspid valve replacement?

Answer 16

Heart block, due to close proximity of conduction bundle to tricuspid annulus (see attached)

Question 17

Valve prostheses types

Answer 17

Mechanical: last longer but need to have lifelong anticoagulation. Bioprosthetic: less durable, no need for anticoag but don’t last as long, better for elderly

Question 18

Small cell lung cancer

Answer 18

Centrally located. Sensitive to chemo, no surgery indicated. Poor prognosis, majority are metastatic at time of diagnosis.

Question 19

Non-small cell lung cancer

Answer 19

Includes squamous cell, large cell, and adenocarcinoma. Not very responsive to chemo. Debulking surgery indicated. Malignant pleural effusion precludes curative resection. Prognosis varies with type/stage.

Question 20

Squamous cell cancer location

Answer 20

Central (remember: centrally located lung cancer are the two “S”entral ones: small cell and squamous

Question 21

Adenocarcinoma and large cell lung cancer are located..?

Answer 21

Peripherally

Question 22

Lambert-Eaton syndrome

Answer 22

Antibodies against presynaptic nerve terminals decrease ACh release. 40% of cases assoc with small cell lung cancer

Question 23

Two main types of thoracic aortic aneuryms

Answer 23

Degenerative: due to abnl collagen metabolism, such as Ehlers-Danlos, Marfan. Atherosclertoic: due to remodeling and dilation of aortic wall.

Question 24

DeBakey classification

Answer 24

Type I: ascending and descending
Type II: ascending only
Type III: descending only

Question 25

Stanford classification

Answer 25

Stanford A: ascending aneurysm
Stanford B: descending aneurysm

NB: ascending is worse

Question 26

Diagnosis of aortic dissection

Answer 26

CXR first. Stable: CT angio. Unstable: echo (TEE or TTE)

Question 27

Treatment of aortic dissection

Answer 27

Control HTN with beta-blocker. Surgical repair (only 1/2 of those that make it to surgery survive)

Question 28

What is one major complication of aortic aneurysm repair?

Answer 28

Paraplegia (due to anterior spinal artery ischemia)

Question 29

Crawford classification of abdominal aortic aneurysm

Answer 29

Type I: most of descending thoracic aorta + abdominal aorta proximal to renal arteries.
Type II: most of descending thoracic aorta + abdominal aorta distal to renal arteries.
Type III: distal 1/2 of descending thoracic aorta + abdominal aorta proximal to renal arteries
Type IV: distal 1/2 of descending thoracic aorta + abdominal aorta distal to renal arteries

Question 30

Screening for AAA

Answer 30

One time US screening for any male that ever smoked, from age 65-75