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Cardiac Surgery (shared) > Pericardial Surgery and Cardiac Tumors > Flashcards

Pericardial Surgery and Cardiac Tumors Flashcards

1
Q

Blood Supply of the Pericardium

A
  1. Pericardiophrenic arteries
  2. Branches if the IMAs
  3. Branches directly from the Aorta
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2
Q

Innervation of the Pericardium

A
  1. Vagal Fibers from the Esophageal Plexus
  2. Phrenic Nerve Branches
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3
Q

Pericardial Sinuses

A
  1. Oblique Sinus - pulmonary venous confluence
  2. Transverse Sinus - between the great arteries and dome of the LA and RPA
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4
Q

Normal Pericardial Fluid Volume

A

10-20mL

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5
Q

Ventricular Interdependence

A

Intrapericardial pressure reflects intrathoracic pressure. During inspiration intrathoracic pressure and PVR decreases increasing RV preload causing a leftward shift of the IVS resulting in decreased LV preload and resultant SV reflected by a decrease in BP.

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6
Q

Pulsus Paradoxus

A

Exaggerated Ventricular Interdependence

(during inspiration PVR decreases increasing RV preload causing a leftward shift of the IVS resulting in decreased LV preload and resultant SV reflected by a decrease in BP)

Greater than 10mmHg drop in SBP during inspiration.

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7
Q

Describe the changes to the JVP trace for

Tamponade

vs.

Constrictive Pericarditis

vs.

Restrictive Cardiomyopathy

A

Tamponade

Prominant ‘‘x”

Blunted “y”

Constrictive Pericarditis

Prominant “x”

Prominant “y”

Restrictive Cardiomyopathy

Blunted “x”

Prominant “y”

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8
Q

Partial or Complete Agenesis of the Pericardium

A

Partial Absence of the Pericardium

  • 70% Left
  • 20% Right; Usually Complex and Lethal

Complete Agenesis of the Pericardium

  • Rare
  • Usually asymptomatic and of no consequence
  • Can result in incarceration of the LAA or LV due to excessive mobility within the chest
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9
Q

Pericardial Cysts

A

Most Common Peridarial Disorder

70% Occur at the Right Costalphrenic Angle

Usually Incidental Finding

Symptoms (related to complession or inflammation)

  1. Pain
  2. SOB
  3. Cough
  4. Arrhythmias

Indications for Resection

  1. Large Size
  2. Symptoms
  3. Patient Concern
  4. Question of Malignancy
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10
Q

Beck’s Triad

A

Clinical Manifestations of Tamponade

  1. HoTN
  2. Jugular Venouse Distention
  3. Muffled Heart Sounds
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11
Q

Compenatory Responses to Increased Diastolic Filling Pressures

A
  1. Parallel Increase in PVR and SVR
  2. Tachycardia
  3. Chronic Pericardial Stretch
  4. Increased Preload (expand blood volume)
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12
Q

Symptoms of Pericardial Constriction

A
  1. Fatigue
  2. Exercise Intolerance
  3. Dyspnea/Orthopnea
  4. Peripheral Edema
  5. Ascites
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13
Q

Pathophysiology of Pericardial Constriction

A
  • Impairment of Late Diastolic Ventricular Filling
  • Ventricular Interdependence causes an abrupt leftward shift of IVS (Septal Bounce) and Pulsus Paradoxus
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14
Q

Kussmaul’s Sign

A

JV distension during inspiration

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15
Q

Echocardiographic Findings of Pericardial Constriction

A
  1. Septal Bounce
  2. Pericardial Thickening
  3. Plethoric IVC
  4. Underfilled Chambers
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16
Q

Hemodynamic Indicators of Pericardial Constriction on Cath

A
  1. Square Root Sign

Sudden increase in RV filling pressure in late diastole followed by equilization of diastolic filling pressures

  1. Steep “x” and “y” descent (Restrictive will have blunted “x”)
  2. ***Ventricular Interdependence

discordant increase in RV and decrease in LV pressure curve during inspiration

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17
Q

Constrictive Pericarditis vs. Restrictive Cardiomyopathy

A

Constrictive Pericarditis

  • Dissociation of intrathoracic and intracardiac filling pressures measured by respiratory variation in the gradient between the LVP and PCWP during the rapid filling phase of diastole
  • ***Ventricular Interdependence - discordant increase in RV and decrease in LV pressure curve during inspiration
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18
Q

Causes of Pericarditis

A
  1. Infectious (viral, bacterial, fungal)
  2. Metabolic (uremia, drug induced)
  3. Autoimmune (arthritis, thyroid)
  4. Post-Radiation
  5. Neoplastic
  6. Traumatic
  7. Post-Infarct (Dressler’s Syndrome; 10-15%)
  8. Postcardiotomy Syndrome (5-30%)
  9. Idiopathic
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19
Q

ECG Findings of Pericarditis

A
  1. Diffuse ST elevation (without reciporical changes or Q-waves)
  2. PR depression
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20
Q

Trials on the Treatment of Pericarditis

A

ICAP

  • RCT; NSAIDs vs. Colchicine for First Episode Pericarditis
  • Reduced Persistence and Reccurence

CORP and CORP-2

  • NSAIDs vs. Colchicine
  • Reduced Recurrence
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21
Q

Most Common Bacteria Causing Pericarditis

A
  1. Haemophilus Influenzae
  2. Meningococci
  3. Pneumococci
  4. Staphylococci
  5. Streptococci
  6. Salmonella
  7. TB (developing nations or HIV)
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22
Q

Fungal Causes of Pericarditis

A
  1. Nocardia
  2. Aspergillus
  3. Candida
  4. Coccidioides
  5. Histoplasma
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23
Q

Drugs Associated with Pericarditis

A
  1. Hydralizine
  2. Procainamide
  3. Isonaizid
  4. Methysergide
  5. Cromolyn
  6. Penicillin
  7. Emetine
  8. Minoxidil
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24
Q

Most Common Secondary Tumors of the Pericardium

A

Males

  1. Carcinoma of the Lung (30%)
  2. Carcinoma of the Esophagus (30%)
  3. Lymphoma (10%)

Females

  1. Carcinoma of the Lung (35%)
  2. Lymphoma (20%)
  3. Carcinoma of the Breast (10%)
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25
Q

Risk Factors for Postop Pericardial Effusion

A
  1. Increased BSA
  2. PE
  3. Immunosuppression
  4. Surgery (Transplant or Aortic Aneurysm)
  5. Long CPB Time
  6. Urgency
  7. Renal Failure
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26
Q

Findings of Postoperative Tamponade

A
  1. Early Postop Bleeding with Decreased or No CT Output
  2. Tachycardia
  3. Narrow Pulse Pressure
  4. Pulsus Paradoxus
  5. Increased CVP
  6. Oliguria
  7. Acidosis
  8. Elevated Lactate
  9. Escalating Inotropes/Vasopressors
  10. Decreased Cardiac Index
  11. Decreased MVO2
  12. Electrical alternans
  13. Pericardial effusion
27
Q

Management of Postoperative Tamponade

A

Correct…

  1. Coagulopathy
  2. Hypothermia
  3. Acidosis
  4. Hypovolemia

Urgent Surgical Mediatrinal Exploration

28
Q

Outcomes following Emergent Mediastinal Exploration in the ICU for Tamponade

A

Perioperative Mortality - 85%

Sternal Wound Infection - 5%

29
Q

Echocardiographic Findings of Tamponade

A
  1. Early Diastolic RV Collapse
  2. Early Systolic RA Collapse
  3. IVC Dilitation (>50%)
  4. Increased Ventricular Interdependence with respiration
  5. Decreased mitral inflow with inspiration
30
Q

Approaches to the Pericardial Window

A
  1. Thorascoscopy
  2. Anterior Thoracotomy
  3. Subxiphoid
31
Q

Waffle Procedure

A
  • For Constrictive Pericarditis of the Viseral Pericardium/Epicardium
  • Longitudinal and Transverse Incisions in the Epicardium 1cm Apart
32
Q

Principle and Margins of Dissection for Surgical Pericardiectomy

A

Principle

  • Complete Pericardial Resection

Margins

  1. Anterior from Phrenic-to-Phrenic Nerve
  2. Posterior from the Reflection Around the Vena Cava to the Pulmonary Veins
33
Q

Outcomes Following Surigcal Pericardiectomy

A

Operative Mortality 5-10%

1-year Survival 90%

10-year Survival 85%

*Except Post-Radiation Constrictive Pericarditis - 60/0%

34
Q

Frequency of Benign vs. Malignant Primary Cardiac Tumors

A

75% Benign

25% Malignant (of which 75% are sarcomas)

35
Q

Pathological Origins of Cardiac Tumors

A
  1. Pseudotumors (thrombus)
  2. Heterotopias/Ectopic Tissue Tumors (AV Node, Teratomas, Thyroid Tumors)
  3. Mesenchymal (Endocardial Hamartomas, Papillary Fibroelastoma)
  4. Myocardial Hamartomas (Rhabdomyoma, Purkinje Cell)
  5. Fat (Lipomatous hypertrophy of the IAS, Lipoma, Liposarcoma)
  6. Fibrous or Myofibroblastic Tissue (Fibroma, Fibrosarcoma, Leiomyosarcoma)
  7. Vascular Tumors (Hemangioma, Angiosarcoma)
  8. Mix/Unknown Histogenesis (Myxoma)
  9. Neural Tumors (Granular Cell, Schwannoma/Neurofibroma)
  10. Paraganglioma
  11. Lymphoma
  12. Mesothelioma
36
Q

Frequency of Benign Cardiac Tumors in Adults

A
  1. Myxoma (50%)
  2. Lipoma (20%)
  3. Papillary Fibroelastoma (20%)
  4. Hemangioma (5%)
  5. AV Node Mesothelioma (5%)
  6. Fibroma
  7. Teratoma
  8. Granualr Cell Tumor
  9. Neurofibroma
  10. Lymphangioma
  11. Rhabdomyoma (<1%)
37
Q

Frequency of Benign Cardiac Tumors in Children

A
  1. Rhabdomyoma (50%)
  2. Teratoma (20%)
  3. Fibroma (15%)
  4. Myxoma (15%)
  5. Hemangioma
  6. AV Node Mesothelioma
  7. Neurofibroma
38
Q

Myxomas

A
  • 50% of Adult Cardiac Tumors
  • 15% of Childhood Cardiac Tumors (Rare in infants)
  • F > M
  • Peak Incidence 3-6th Decade
  • Solitary (95%)
  • 75% in Left Atrium (10-20% Right Atrium)
    • Right atrial myxomas have a higher association with multiple lesions
  • Low Recurrence Rate (1-5%)
  • Majority Sporatic (5% Familial)
39
Q

Familial Myxomas

A
  • 5% of Myxomas
  • Autosomal Dominant
  • Abnormal Chromosomal Genotype
  • Present at Younger Age
  • F = M
  • 20% Multiple Tumors in the Atria or Ventricles
  • Higher Recurrence Rate (20-60%)
  • 20% Complex Myxomas with Assoc. Conditions
    1. Adrenocortical Nodule Hyperplasia
    2. Sertoli Cell Tumors
    3. Pituitary Tumors
    4. Multiple Myxoid Breast Fibroadenomas
    5. Cutaneous Myomas
    6. Facial or Labial Pigmented Spots
40
Q

Carney’s Syndrome

A

Familial Syndrome

Autosomal Dominant (chromosome 17)

X-Linked Inheritance

M > F

Primary Pigmented Nodular Adrenocortical Disease

  1. Hypercortisolism
  2. Cutaneous Pigmentous Lentigines and Blue Nevi
  3. Cardiac Myxomas
  4. Other endocrine tumors
    1. Thyroid
    2. Testes
    3. Ovaries
    4. Pituitary Adenoma
41
Q

Common Presentations of Myxomas

A

CHF (Obstruction) 60%

Embolization 30%

Constitutional Sx 20%

Death occurs from obstruction or emoblization in 8% of paitents awaiting surgery

42
Q

Surgical Approach to Myxoma Excision

A

Intraoperative TEE to check for other assoc. tumors

Bicaval cannulation

Cross clamp the aortia prior to manipulating the LA

Transmural excision of the stalk/attachment

Wall suction wil tumor exposed to prevent systemic embolization

Mortality risk 5% (10% if ventricular myxoma)

43
Q

Lipomas

A

Encapsulated

Pericardium

Subepicardium

assoc. with pericardial effusions

Subendocardium

Intra-atrial septum

assoc. with compressive/obstructive Sx or arrhythmias

M=F

Most commonly RA or LV

44
Q

Lipomatous Hypertrophy of the Intra-Atrial Septum

A

Non-encapsulated

  1. Elderly
  2. Obese
  3. Females

Benign, may be assoc. with arrhythmias

MRI helpful for tissue characterization for diagnosis

45
Q

Papillary Fibroelastomas

A

Heart valves or adjacent endocardium

Asymptomatic until they embolize or obstruct (usually coronary ostia)

AV=Semilunar valves

46
Q

Rhabdomyomas

A

Most frequent tumor in Children

Sporadic

Assoc. with Tuberous Sclerosis

  1. Epilsepsy
  2. Mental retardation
  3. Sebaceous Adenomas

Ventricles > Atrium

90% Multi-site involvement

47
Q

Presentation of Rhabdomyomas

A

Valvular or subvavlular stenosis

Ventricular Tachycardia

Sudden Death

48
Q

Surgery for Rhabdomyomas

A

Surgical resection with enucleation before 1-year of NO tuberous sclerosis

Tuberous sclerosis assoc. with multiple lesions and has a very poor prognosis

49
Q

Fibromas

A

2nd most common benign tumor

80% in children

M=F

Occur in the Ventricule or Ventricular Septum

Non-encapsulated elongated fibroblasts

50
Q

Presentation of Fibromas

A

Chamber obstruction

Contractile dysfunction

Arrhythmias

Sudden Death (25%)

51
Q

Surgical Resection of Fibromas

A

Resection/enucleation recommended if vital structures NOT involved

Complete resection is curative

If vital structures are involved then partial resection can be performed but is palliative

Transplantation is an option

52
Q

Mesothelioma of the AV Node

A

AKA… ​

  1. Polycystic tumor
  2. Purkinje tumor
  3. Conduction tumor

Presents with…

  1. AV block
  2. Ventricular fibrillation
  3. Sudden death
53
Q

Pheochromocytomas

A

Chromaffin cells of the sympathetic nervous system

Produce catecholamines (norepinephrine)

Young Adults

M=F

60% in the roof of the LA

54
Q

Paragangliomas

A

Endocrine tumor

Secretes catecholamines

Most commonly in the posterior mediastinum

High vascularity contributes to risk assoc. with surgical resection

55
Q

Teratoma

A

Most common in infants and young children

80% Benign

56
Q

Castleman Tumor

A

Lymphoproliferative Disorder

Histological types

  1. 90% Hyaline Vascular (benign)
  2. 10% Mixed-cell type (malignant)
57
Q

Primary malignant tumors (sarcomas)

A

Histological Types

  1. Angiosarcomas
  2. Rhabdomyosarcomas
  3. Malignant mesotheliomas
  4. Fibrosarcomas

Anatomical Types

  1. Right sided (most angiosarcomas; infiltrative; metastisize early; neoadjuvant chemo)
  2. Left sided (more solid; present with CHF; mistaken as myxomas; rapidly recure)
  3. PA (present with R-sided HF/PE Sx; better prognosis)

Survival only 10% at 1-year

58
Q

Angiosarcomas

A

M > F

80% RA

Invade adjacent structures

Present with Obstruction and right-sided HF

Histology - vascular channels lined with typical anaplastic epithelail cells

Metastasize to the lung/liver/brain

90% dead within 9-12 months of Dx

59
Q

Malignant Fibrous Histiocytomas

A

Histology - fibroblasts of histioblasts - mixture of spindle cells in a storiform pattern and polygonal cells

Often mistaken for myxomas

Patients die of local recurrence more commonly than metastatic disease

60
Q

Rhabdomyosarcomas

A

M = F

Commonly multicentric, arising in both ventricles

Invasive

Histology - pleomorphic nuclei, spidery streaming eosinophilic cytoplasm, muscle-like pattern

Survival < 12-months

61
Q

Secondary/Metastatic Cardiac Tumors arise from what types of cancer?

A
  1. Leukemia
  2. Melanoma
  3. Lung cancer
  4. Sarcoma
  5. Breast cancer
  6. Esophageal cancer
  7. Ovarian cancer
  8. Kidney cancer
  9. Gastric cancer
  10. Prostate cancer
  11. Colon cancer
  12. Lymphoma
62
Q

Most common cardiac sites of metastasis

A
  1. Pericardium
  2. Epicardium
  3. Myocardium
  4. Endocardium
63
Q

Frequency of Renal Cell Carcinoma invasion of the IVC and RA

A

Invades the IVC in 10% of cases

Reaches the RA in 40% of these cases

If renal primary fully resectable survival is 75% at 5-years

Cardiac Surgery (shared) (14 decks)

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