Potpourri 1.0 (1-100) Flashcards
Patient with respiratory failure and diffuse pulmonary infiltrates
How often will the results of a Bx result In a change of therapy?
45-75%
Patient with respiratory failure and diffuse pulmonary infiltrates:
What is the frequency of perioperative complications after a bx?
20-40%
Patient with respiratory failure and diffuse pulmonary infiltrates :
What proportion of those who undergo Bx will survive the hospitalization?
1/3
Patient with respiratory failure and diffuse pulmonary infiltrates:
How often will an open lung Bx reveal a dx?
47-68%
Sympathectomy nerve roots responsible for Palmer hyperhidrosis
R3 + R4 - completely dry
Top of R3 for isolated palmar hyper hyperhidrosis
Sympathectomy nerve root responsible for axillary
R5 clipping alone experienced no compensatory hyperhidrosis, and none regretted having the surgery
Sympathectomy nerve root responsible for facial blushing
T2
Percents sympathectomy patients with compensatory hyperhidrosis
49-99% Sesat- 50%
Bronchial adenoma
Now known as typical carcinoid
What characterizes the histology of a typical carcinoid?
Rare spindle cells
What is the 5-year survival of a typical carcinoid?
5 year survival is 90%
Important infections that are NOT / Relative contraindications for Lung txp recipient
- Colonization with highly resistant or highly virulent fungi / mycobacteria
- Hep B/C - Ok if no clinical, radiologic, or serologic signs of cirrhosis
- should be done at a center with experienced hepatology unit
- HIV + : if - undetectable HIV RNA , and with no HIV related symptoms
- Infection with Burkholderia cenocepacia, B. Gladioli, Mycobac abbesses if sufficiently controlled
Infections which are absolute contraindication to lung txp recipient
- Chronic infection with highly virulent microbes poorly controlled pre transplant
- Evidence of active Mycobacterium tuberculosis infection
Effect of obesity on Lung Txp Candidacy
- Class II or III obesity (BMI > 35) is a contraindication
- Class I obesity (BMI 30-34.9) particularly truncal obesity is a relative contraindication
Important infections NOT Relative / contraindications for Lung txp recipient candidacy:
-
Colonization with highly resistant or highly virulent fungi / mycobacteria
- eg: chronic pulmonary infection expected to worsen after infection
-
Hep B/C: - Ok if no clinical, radiologic, or serologic signs of cirrhosis
- should be done at a center with experienced hematology unit
- HIV (+) : if undetectable HIV RNA , and with no HIV related symptoms
- Infection with: Burkholderia cenocepacia, B. Gladioli, Mycobac abbesses if sufficiently controlled
Infections which are absolute contraindication to lung txp recipient
- Chronic infection with highly virulent microbes poorly controlled pre transplant
- Evidence of active Mycobacterium tuberculosis infection
Effect of obesity on Lung Txp Candidacy
- Class II or III obesity (BMI > 35) is an absolute contraindication
- Class I obesity (BMI 30-34.9) particularly truncal obesity is a relative contraindication
Acute lung transplant rejection - Histologic phenotype
Acute rejection of the lung may be localized or diffuse. The histologic findings : perivascular infiltration of mononuclear cells
Optimal method to diagnose acute lung transplant rejection
Bronchoscopy with transbronchial biopsy of at least three sites in the involved lobe is both sensitive and specific for the diagnosis of acute rejection.
Cyclosporine ADE
- Cyclosporin causes vasoconstriction of the renal arterioles resulting in hypertension and nephrotoxicity.
- Cyclosporin is also associated with neurologic symptoms such as seizures and tremors.
established regimen for maintenance therapy for immunosuppression following OHT
tripple therapy
- cyclosporine
- Azathioprine
- Prednisone
Pulmonary hypertensive crisis after AV canal repair.
- Occurs with increasing frequency post repair ( after 3-4 months)
… may account for the increased mortality at this age group.
Pulmonary hypertensive crisis – what is it?
- An acute rise in the PA pressures + Reduced cardiac output through the pulmonary circuit → hypoxia → further exacerbating the increased pulmonary vascular resistance.
- Right ventricular dilation shifts the interventricular septum toward the left ventricle (LV), impeding LV filling and further compromising cardiac output.
- Systemic hypotension, _metabolic and respiratory acidosis can ensu_e.
-
Outcomes:
- Pulmonary hypertension (PH) patients have higher mortality during surgical procedures, ranging from 4%-24%.
- Pulmonary hypertensive crisis in the perioperative setting is associated with even worse outcomes > 50%.
treatment of 6-month-old child, complete AV canal, PDA, and FTT
immediate complete intracardiac repair with ligation of patent ductus arteriosus
Contraindications to the use of indomethacin to close a PDA
- Renal impairment
- sepsis
- coagulopathy
- intracranial hemorrhage
- liver failure
Renal failure and necrotizing enterocolitis are potential complications of indomethacin use.
Blood supply to the latismus
Thoracodorsal - a branch of the sub scapular
Blood supply to the pec major
thoracoacromial artery (aka - acromiothoracic artery) –> pectoralis branch
Blood supply to the Serratus
Subscapsular -
A branch just before the thoracodorsal
Percent of does my tumors occurring in the chest
20%
Where do most does more tumors tumors occur
50% occur in the abdomen
Histology of desmoid tumors
Cytology appears frequently benign and differentiation from fibrosarcoma is based on cellularity and bland cytology where mitotic activity in the absence of a herringbone pattern
Natural history of desmoid tumors
- arise from the fascia and connective tissue.
- Frequently asymptomatic until they become large (5 to 10 cm).
- Pain is frequently associated with involvement of the intercostal nerve.
- Do not metastasize, but local recurrence is common.
Recurrent rate of desmoid tumors
Up to 20% with negative margins
Five-year survival for desmid tumors?
90%
percent of patients with a TE fistula who have a sentinel bleed
40-50% – massive bleeding follows hours to days
surgical repair of a tracheal innominate fistula with massive bleed
-sternotomy -posterior repair of the innominate in a contaminated field should not be attempted - artery should be ligated and divided - trachea repeated and buttressed by muscle
Index to evaluate pectus
haller index : wide over narrow > 3 is significant
timing of surgery for pectus
older than 3-5 years
Barretts Esophagus follow up
Periodic endoscopic surveillance for dysplasia. Biopsies in the four quadrants of the esophagus,
- No / low dysplasia: every 2 cm
- High grade dysplasia: every 1 cm
if _no dysplasi_a on two separate occasions: followed with endoscopy every 3 to 5 years.
If l_ow-grade dysplasia:_ a repeat endoscopy is performed to confirm it, and repeat endoscopy is then performed annually.
Recommendations for patients with Barrets and high grade dysplasia
should be offered surgical resection (esophagectomy).
alternatively, i_ntensive surveillance_ every 3 months and local endoscopic therapy
Mechanics for preoperative eval for GERD
pH probe 5cm above the LES (determined by manometry) Normal diet with no food with pH 7
Data for pre-op monitoring from pH probe
- correlation w sx - time pH
Best pre-op indicator for successful Nissen for GERD
an abdominal ph score from 24 hour PH monitoring … ie. a pH 5% of the time
when is the Toupet wrap used ?
toupee wrap is 270 degree classically used with diminished esophageal peristalsis
absolute indication for surgery for active endocarditis
- Fungal endocarditis
- Since no adequate antimicrobial therapy is available for fungal endocarditis
- uncontrolled infection with persistent bacteremia
- moderate to severe heart failure due to valve dysfunction.
Indications for surgery in native right side infective endocarditis
Indications for surgery in right-sided native valve bacterial endocarditis include:
- right-sided heart failure
- gross valvular insufficiency in the absence of heart failure
- extravalvular extension
- vegetations
- myocardial abscess or fistula
- heart block,
- multiple symptomatic pulmonary emboli continued sepsis.
typical etiology of right side endocarditis
usually associated with IVDA
Most common organism causing native valve endocarditis
Streptococci
Most common cause of prosthetic valve endocarditis > 1 year after surgery
- S. viridans
- Enterococcus
- S. pneumoniae.
Most common cause of prosthetic valve endocarditis (1)?
Staphylococcus epidermidis
Most common bacteria for subacute endocarditis?
Most common bacteria for subacute endocarditis?
- Streptococcus viridans
- Enterococci
- Staph epidermidis
- gram negative coccobacilli
Major criteria for surgery for endocarditis
Major criteria :
-
Positive blood culture associated _with eithe_r:
- new or changing murmur
- embolic phenomena
- A new or changing murmur in CHD patient or previous valve damage, with either:
- embolic phenomena
- fever/anemia./splenomegaly
LES pressure considered “weak”
Antireflux procedures in scleroderma
Some improvement but not as efficacious
Non LES causes of GERD
- Delayed gastric emptying
- Pyloric stenosis
- Gastric mass
- Poor esophageal muscle tone (as in scleroderma )
Esophagus - area of frequent entrapment
the area of the aortic arch consistently demonstrates decreased amplitude, velocity and slope of contractions. - swallowed radionucleotide gelatin capsules demonstrated entrapment and dissolution of the capsule in 40% of patients at the level of the aortic arch. – Wet swallowing cleared all but one capsule, suggesting that compression by the aortic arch, the left main stem bronchus, and the left atrium contribute to depressed motility and the potential for entrapment of foreign bodies.
Four landmarks of the UES
- C6-7 vertebral bodies.
- 15 cm from the upper incisor teeth.
- cricoid cartilage
- Inferior thyroid artery
Risk of bioprosthetic degeneration in patients
(% degeneration at 10 years)
30-35 years old: risk of required reoperation for structural valve deterioration is 50% at 10 years.
younger than 30 years:75% at ten years.
Combined thromboembolism / bleeding risk for mechanical valve
1-2% per patient-year.
In elderly patients (>70), the risk of bleeding approaches 10% per patient per year.
Cause of post op SAM after all pharmacologic measures have been taken
usually a discrepancy between the residual anterior and posterior leaflet heights the septal-lateral diameter of the mitral annulus following ring annuloplasty.
Approach to repair Bochdaleck hernia
Right - thoracotomy
Left - abdomen
Arrhythmia associated with congenitally corrected TGA
CHB high risk after repair of associated cTGA - Risk after repair of ventricular septal defect and subpulmonary stenosis, can be as high as 40%
When is a Balloon atrial septostomy used ?
Balloon atrial septostomy: creates an unrestrictive atrial septal communication.
Used in the palliation of anomalies that require mixing of systemic and pulmonary venous returns t_o prevent severe cyanosis eg_:
- d-transposition of the great vessels
- when pulmonary venous return is obstructed by severe mitral stenosis
- atresia (as in some complex single ventricle anomalies).
- NOT TOF
Failure of LES To relax
Achlasia
Failure of the les to contract
GERD
Idiopathic motor disease of the esophagus Hypomotility
Achlasia
Hypermotile Idiopathic motor disorders of the esophagus
- DES
- Nutcracker
- Hypertensive LES
- Disorders NOS
Idiopathic motor disease of the esophagus Hypomotility
Achlasia
Idiopathic motor disorders of the esophagus Hypermotile
- DES 2. Nutcracker 3. Hypertensive LES 4. NOS
Manometry of Achlasia
Because of the obstruction to the esophagus there is: Simultaneous isobaric increase in the esophageal pressure - with no change in the LES
Cork screw esophagus
- Etiology?
- Manometry?
- Rx?
AKA: Diffuse esophageal spasm
- Etiology: unclear, muscle hypertrophy, degenerative vagus, Normal prox 1:3 of esophagus
- Manometry: Triple peak manometry Les occasional incomplete relaxation
- Rx: nitro, Ccb - but trouble with increase in dose→ Long myotomy
EGFR associated with what lung cancer
Adeno ca
IHC marker for melanoma?
Melanin S100 NSE
% of mets melanoma to sites other than the esophagus
50%
5 year survival for melanoma met to esophagus
5-37%
Stemi 95% stenosis of lad 14 hours after acute onset of symptoms
Perc stent Emergency cabg within 6 hours
CAD patient :
- Multiple risk factors
- two lesion on the right: 60 and 80% stenosis
- Preservation of lv function
Life style modification
CAD
“Studies”- what is the cross over from angioplasty to surgery and surgery to angio
EAST
Angio to surgery 22%
Surgery to Angio 13%
Rate of revascularizatuon after Angio and surgery in “studies”?
After Angio : 40-59%
After surgery: 20%
Feline esophagus
what is it?
Epidemiology / Phenotype?
Rx?
- Feline esophagus or ringed esophagus
-
Phenotype:
- See more in males
- Both children and adults
- Atopic individuals
-
Rx:
- remove the allergen
- Oral fluticasone
- Dialation helps sx but is not permanent
Mediastinal tumor ,+ afp, + hcg
Non-senin Germcell tumor
- Multi drug chemo:
- Cisplatin
- Bleomycin
- Etoposimide
- After chemo if normalized - ressection of residual mass If still elevated - more chemo
Remission rate 5 year survival Nscgt
50-60% remission 50-60% 5 year survival
Arrhythmia associated with Ebstein Anomaly
Atrial tachyarrhythmias can occur with Ebstein’s anomaly after long-standing tricuspid regurgitation has caused right atrial dilatation.
An accessory conduction pathway (e.g., Wolff-Parkinson-White syndrome) occurs in approximately 15% of patients with Ebstein’s anomaly.
Tricuspid atresia is not associated with any particular rhythm abnormalities, except for those patients with long-standing right atrial dilatation after an atriopulmonary Fontan procedure.
Arrhythmia after ccTGA
The incidence of complete heart block in congenitally corrected TGA after repair of associated anomalies, especially ventricular septal defect and subpulmonary stenosis, can be as high as 40%. Appreciation of the abnormal anterior location of the conduction tissue has reduced the risk of surgically-induced heart block considerably. However, these patients have a continuing risk of spontaneous, late-developing heart block
% of valve and CABG patients who require permament pacemakers
CABG: 1%
Valve : 3-6%
Acid clearing test
Ability of distal esophagus to clear a 10ml bolus of acid back to the stomach Does not necessarily indicate reflux esophagitis or GERD
Bernstein Acid Perfusion Test
Assesses the patient’s subjective response to acid in the distal esophagus.
Positive in 30% of patients who do not have GERD.
Manometry characterization of Achlasia
Esophageal a peristalsis Elevated baseline pressure of esophageal body (pressurization ) Poorly relaxing LES (possibly htn)
Manometry findings of Nutcracker esophagus
Hypertensive peristalsis and normal LES It cracks nuts !
Manometry Findings of DES
Simultaneous esophageal body contractions (>20%) in association with normal peristalsis sequences LES is thought to be normal but may be htn
Abnormal demeester score
>14.72
Damus-Kaye-Stansel Procedure
Used in HLHS w/ sub aortic obstruction:
- division of the main pulmonary artery
- with anastomosis to the aorta (Damus-Kaye-Stansel procedure)
- may be required to prevent the development of severe ventricular hypertrophy
Most common cardiomyopathy for which children need to undergo txp
Dialated cardiomyopathy
Trusler’s Formula
Formulates the size of a pulmonary aa band can be used as part of single ventricle surgery calculation circumference = 20+wt (kg)
In PAB palliation of single ventricle what is the ideal PA pressure ? sat?
1/3 systemic O2 sat 75%
Warden repair
Supra cardiac anomalous pvr ( as may be seen with a sinus venous) Svc is ligated Pulm veins attached to RA appendage Then the blood flow from pv is routed though the asd via a baffel
Complication to two patch repair of sinus venous Asd
Frequently w sa node dysfunction
Mortality associates with reop prosthetic valve endocarditis
25-50%
Overall survival rate for adult pt on ECMO? For ARDS?
Overall : 47% ARDS: 60%
Extra lobar sequestration
the rarer form of sequestration - extralobar sequestration - 1. most commonly found in men a. (three to four times the incidence in women) 2. usually presents with respiratory compromise in infancy or early childhood. a. Over 90% are discovered by age ten. 3. Other congenital anomalies are found in 60-75% of these children - - abnormal diaphragmatic development is most commonly identified. 4. Vascular supplied by aberrant systemic vessels arising from the thoracic (40-45%) or abdominal (30-35%) aorta or by intercostal arteries (10%). Venous drainage of these lesions occurs via the systemic circulation through the hemiazygos, azygos, or intercostal veins or directly into the inferior vena cava.
