Potpourri 2.0 Flashcards
Course of the thoracic duct in the lower chest
the thoracic duct ascends:
- anterior and to the right of the vertebral column
- behind the esophagus
- between the aorta and the azygous vein.
what type of sequestration is associated with CDH
intralobar sequestrations are frequently associated with congenital diaphragmatic hernia.
CXR in patients with Bronchial Atresia
In patients with bronchial atresia, the distal lung becomes hyperinflated because air enters the pulmonary parenchyma via small collateral airways, such as the pores of Kohn, and is unable to exit through the bronchus.
Extra lobar sequestration
the rarer form of sequestration -
- most commonly found in men (three to four times the incidence in women)
-
Presents with respiratory compromise in infancy or early childhood.
- Over 90% are discovered by age ten.
- Other congenital anomalies are found in 60-75% of these children
- abnormal diaphragmatic development is most commonly identified.
- 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.
Ecmo with plasma leak across the membrane lung
Expected complication over time Gradual decrease in pump oxygenate efficiency
Initial treatment of delayed paraplegia after descending aorta repair
re-institution of csf drainage
Av canal defect, PA pressure Shunt
AV canal with a non-restrictive vsd PA pressures may approach systemic In a pt with no pulm vascular disease a Qp/Qs: 3:1 is ok Can administer O2 to see if reversible. Trisomy 21 is particularly susceptible to pulm Vasc disease
In patients w CAD and mr, what predicts long term survival
Severity of the MR
Patient with development of a new systolic murmur and cardiogenic shock four days after a myocardial infarction
suggests the development of a postinfarction ventricular rupture defect or acute mitral regurgitation. Placement of a Swan-Ganz catheter with evaluation of a possible stepup in oxygen saturation between the right atrium and pulmonary artery allows the clinician to differentiate between these two events. If the patient is found to have a postinfarction ventricular septal rupture, hemodynamic stabilization with pharmacologic support, and an intra-aortic balloon pump is the most appropriate course, followed by cardiac catheterization and urgent operation.
Acute ischemic MR- with or without pap muscle rupture
Rupture of pap - usually an indication for emergent mitral valve repair.
Without pap rupture is much more common- after load reduction via IABP or Rx improves MR MILD to mod MR can usually be handeled with Rx.
Histology of Achlasia
The etiology of this condition is unknown but histopathologic studies have consistently found loss of ganglion cells in the myenteric plexus of the esophageal wall.
Most likely cause of syncope in patients with AS
Faulty barro receptor response
Pulmonary vascular considerations for performing a bi-directional Glenn
Prohibitive: Pa pressures above 15-20mmHg Or resistance above 3-4 wu
AV canal Which leaflets are most variable
Left superior and inferior
Aortic valve and aortic / mitral continuity in AV canal defect
Aortic valve is elevated and anterior The mitral aortic continuity is abnormal
Fossa ovalis in an AV canal
Usually normal
AV canal What associates anomaly carries the highest mortality risk?
Total anomalous pulmonary venous connection. TAPVR Rare but 50% mortality
When is heart block most likely after repair of an AV canal
TOF Or use of a prosthetic replacement
Major risk factors for death after surgical tx of an AV canal
- Single pap muscle
- Additional vsd
- Accessory valve orifice
- Poor preop status
🤔young age is not a risk factor
Position of the stellate chain ganglia
Along the posterior head of each rib
Function of the T2 ganglia
Hand Needs to be tx for palmar hyperhidrosis
Ganglia supplying the axila
T4 and T5
Position of the stellate chain ganglia
Along the posterior head of each rib
Function of the T2 ganglia
Hand Needs to be tx for palmar hyperhidrosis
Ganglia supplying the axila
T4 and T5
sx of Zenker’s diverticulum
- Regurgitation of undigested food particles
- Abnormal noise during swallowing
- Halitosis
- Rare event of a visible swelling in the neck, and ear, nose,
- Rare: throat symptoms
incidence of salivary fistula after cervical diverticulectomy
Nevertheless, data from the literature indicate an incidence of salivary fi stula varying between 1% and 25%.
Survival for bilateral lung and heart lung txp
Ishlt: For both: 1 year: 70-75% 5 year: 40%
% of lung txp patient to develop BOOP at one year ?
50%
Shatzki’s ring
mild submucosal fibrosis at the squamocolumnar junction of the leading edge of a sliding hiatal hernia. Patients are often asymptomatic. Although a sliding hiatal hernia is always present, symptoms of reflux or evidence of active esophagitis need not be present. Treatment is directed toward relief of dysphagia and is usually easily accomplished with dilatation to 50 French size using Maloney or Savary dilators. If dysphagia recurs, dilatation can be repeated. An antireflux procedure is only required in patients with symptoms or complications of reflux not controlled medically.
when does dysphagia occur with Shatki’s ring
Dysphagia or sudden aphagia usually do not occur until the diameter of the web is less than 12-13 mm.
Factors which may impact failure of reflux surgery
Several mechanical “stressors” have been studied in relationship to recurrent symptoms and fundoplication failure, including:
- patient height
- body mass index (BMI)
- postoperative gagging
- vomiting
- weight lifting (greater than 100 pounds)
- coughing
- hiccupping
- motion sickness
- retching
- belching
how does stricture impact the recurrence after a reflux procedure
stricture increases the incidence of recurrence
Thal fundic patch
technique in which the esophageal stricture is incised and overlaid with a patch of stomach has been abandoned because of complications and because poor control of reflux allows continued esophagitis
Definition of short esophagus
the only accepted definition of short esophagus by thoracic surgeons has been the intraoperative inability to obtain at least 2.5cm of distal esophagus below the diaphragmatic crura.
what sx are most likely not to improve after a fundoplication
atypical sx such as cough
Damage to the RLN In coarctation repair
Transient paralysis of the vc that returns in 6-12 months
Most common complication of Coarc repair
Recoarc
LV compliance in HOCM
left ventricular hypertrophy results in diminished left ventricular compliance with a resultant increase in left ventricular diastolic filling pressures. Left ventricular compliance changes are documented by changes in the LVEDP/LVEDV relationship
HOCM inheritence
AD
Signs differentiating HOCM from AS
Three differentiating signs include:
- a late onset systolic ejection murmur between the left sternal border and apex
- a jerky (“spike and dome”) arterial pulse
- a palpable left atrial contraction
Effect of venting on myocardial oxygen requirements
Venting: Complete emptying with a left ventricular vent decreases oxygen requirement to 5.0-6.0 ml/(min*100gm heart) Baseline: greater than 20 ml/(min*100gm heart) when ejecting normally.
Baseline oxygen comsumption on the heart ?
Baseline: greater than 20 ml/(min*100gm heart) when ejecting normally.
Effect of fibrillation on oxygen consumption of the heart ?
Effect of fibrillation Fibrillation at normothermia increases O2 consumption compared to the empty beating state, although cooling the fibrillating heart to 28 C or less decreases oxgen uptake by over 50%.
The most effective means of protecting the heart
Chemical cardioplegia the most effective means of decreasing oxygen consumption, and even at normothermia the potassium arrested heart only consumes : ❤️❤️❤️approximately 1.0 ml/(min*100 gm heart). The figure, adapted from Buckberg’s seminal work, demonstrates myocardial oxygen consumption using four different myocardial protection strategies in order of decreasing myocardial oxygen requirements (left to right on the graph
ECG indication of ventricular aneurysm
- The presence of a ventricular aneurysm is suggested by persistent ST elevation on the electrocardiogram despite the absence of pain
what are the priorities in information for patients for end of life decisions ?
-
Priority of decisions made for incompetent patients?
- Consensus decisions by family members are l_east helpful_ in making end-of-life decisions, because the least involved family member often has the most outspoken views.
- advanced directives and living wills are frequently not readily applicable or not relevant to specific postoperative situations.
- A designated health care proxy is often the most reliable and useful resource in EOL decisions.
- Prior knowledge of patient preferences is the most helpful guide to making difficult decisions about the end of life.
Proportion of patients with hypoxic respiratory who show improvements with prone positioning
Prone positioning allows a decrease in FiO2 in 60-70% of patients with severe acute hypoxic respiratory failure.
Heparin - chemistry and mechanism of action
Heparin and certain naturally occurring glycosaminoglycans increase the binding of antithrombin to thrombin by more than 1000-fold.
Antithrombin deficiency
Antithrombin seems to be the most important circulating inhibitor of thrombin.
Antithrombin deficiency
Antithrombin deficiency is associated with a thrombotic tendency,
multiple mutations of the antithrombin gene causing thrombosis.
Acquired antithrombin deficiency has been reported in association with CPB,
especially in infants with less well developed hepatic function.
What populations are especially prone to antithrombin deficiency?
- infants with less well developed hepatic function.
- preoperative heparin
- CPB
What is “heparin resistance”
What is “heparin resistance.”?
syndrome of acquired antithrombin deficiency associated with CPB
Treatment of heparin resistance on CPB?
CPB:
unfractionated heparin (UFH) should be supplemented with either:
- antithrombin concentrates,
- short-acting direct thrombin inhibitor (e.g. bivalirudin)
- short-acting platelet glycoprotein IIb/IIIa antagonist.
The use of increasing doses of heparin or of low-molecular weight heparin in these patients is not helpful and may be associated with either thrombotic or bleeding complications.
Anticoagulation Rx for patients with HIT:
Three agents have FDA approval for anticoagulation in HIT/HITT syndrome patients:
Mechanism: Each binds thrombin irreversibly and inhibits its activity, and each is excreted by the kidneys
- lepirudin, longest half-life (40-120 minutes)
- bivalirudin (Angiomax) direct thrombin inhibitor that is readily reversible and its half-life is the shortest of these three drugs.
- argatroban,
of the drugs approved for anticoagulaiton in HIT, which has the shortest half life ?
Three agents have FDA approval for anticoagulation in HIT/HITT syndrome patients
lepirudin, longest half-life (40-120 minutes)
bivalirudin (Angiomax) direct thrombin inhibitor that is readily reversible and its half-life is the shortest of these three drugs.
argatroban,
what type of congenital lung sequestration is the more common:
Intralobar sequestration is more common
Extralobar sequestration
epidemology
the rarer form of sequestration -
most commonly found in men (three to four times the incidence in women)
Extralobar sequestration - how do the kids present?
- Respiratory compromise in infancy or early childhood.
- Over 90% are discovered by age ten.
Extralobar sequestration - frequency with which other congenital abnormalities are discovered
Other congenital anomalies are found in 60-75% of these children
abnormal diaphragmatic development is most commonly identified.
Extralobar sequestration - vascular supply
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.
Extra lobar sequestration
what is the prevelance based on Gender
the rarer form of sequestration -
-
most commonly found in men (three to four times the incidence in women)
*
Extra lobar sequestration - what is the vascular supply ?
- supplied by aberrant systemic vessels arising from the:
- thoracic aorta (40-45%)
- abdominal aorta (30-35%)
- intercostal arteries (10%).
Extra lobar sequestration
venous drainage
- Venous drainage of these lesions occurs via the systemic circulation through the:
- hemiazygos
- azygos
- intercostal veins
- directly into the inferior vena cava.
