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2021 September TSITE Review > Thoracic Surgery > Flashcards

Thoracic Surgery Flashcards

1
Q

Boundaries of cervicoaxillary canal

A

First rib inferiorly Costoclavicular ligament medially

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2
Q

What are the Layers that are seen on esophageal EUS?

A

1st (hyperechoic) epithelium/lamina propria

2nd (hypoechoic) - muscularis mucosa

3rd (hyperechoic) - submucosa

4th (hypoechoic) - muscularis propria

5th (hyperechoic) - paraesophageal tissue/adventitia Muscle = dark (hypoechoic)

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3
Q

Normal Demeester Score

A

Less than 14.72

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4
Q

Preoperative PFT assessment for lung resection

A

Goals: FVC > 50% predicted FEV1 > 50% predicted DLCO > 60% predicted (best predictor of mortality) If FEV1 and DLCO >60% predicted, can resect up to pneumonectomy If less than 60% predicted, calculate predicted postop FEV1 and DLCO - Take the number of remaining segments divided by 18 and multiply by the preop FEV1 and DLCO If PPO FEV1 and DLCO >40%, resection should be tolerated

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5
Q

Incision for innominate artery injury

A

Sternotomy

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6
Q

Incision for proximal right common carotid artery injury

A

Sternotomy

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7
Q

Incision for proximal right subclavian artery injury

A

Sternotomy

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8
Q

Incision for distal carotid artery injury

A

Supraclavicular or anterior SCM

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9
Q

what is the incision for distal subclavian/axillary artery injury?

A

Infraclavicular

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10
Q

Incision for proximal leftsubclavian artery injury

A

Left posterolateral thoracotomy or trapdoor

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11
Q

Management of traumatic coronary artery injury

A

If cardiac dysfunction, initiate CPB and repair/bypass the artery

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12
Q

Indications for VATS in thoracic trauma

A
    • Ongoing hemorrhage
    • Retained hemothorax
    • Persistent pneumothorax
    • Diagnosis and treatment of the diaphragmatic injury
    • Pericardial window for relief of cardiac tamponade
    • Management of thoracic duct injuries
    • Treatment of post-trauma empyema
    • Removal of foreign bodies
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13
Q

NETT trial for LVRS

A

Survival benefit in surgical arm for patients with heterogenous disease (upper-lobe predominant)

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14
Q

Indications for surgery for lung abscess

A
    • Unsuccessful medical treatment after 5 weeks (residual cavity, thick-walled, and larger than 2cm)
    • Suspicion of carcinoma
    • Significant hemoptysis
    • Empyema
    • Bronchopleural fistula
  6. Operation of choice is lobectomy
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15
Q
  1. What is the most common organism in postpneumonectomy empyema?
  2. what does a polymicrobial effusion suggest?
A
  1. Staph. aureus
  2. polymicrobial suggests enteropleural fistula
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16
Q

Management of early post-op BP fistula (

A

Return to OR, resuture bronchus, cover with muscle flap

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17
Q

Indications for surgery in Aspergillosis

A
  • Only operate if there are symptoms
    • (don’t want to operate if you don’t have to)
  • Resect once hemoptysis develops:
  • No role for prophylactic resection:
  • mortality:
    • simple aspergilloma: 5%
    • complex aspergilloma: 33%
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18
Q

when would you decide to operate on a patient with TB?

A
  1. Persistently positive sputum cultures with cavitation after 5-6 months of continuous optimal medical therapy with 2 or more drugs -
  2. Localized pulmonary disease caused by MAI, TB, or another atypical mycobacterium which is drug-resistant
  3. Mass lesion of the lung in area of TB involvement
  4. Life-threatening or recurrent severe hemoptysis
  5. BP fistula in association with a mycobacterial infection that doesn’t respond to chest tube
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19
Q

Treatment of seminomatous germ cell mediastinal tumors

A

Radiation (+/- )cisplatin-based chemotherapy

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20
Q

Treatment of non-seminomatous germ cell mediastinal tumors

A

Cisplatin-based chemotherapy Surgery if markers normalize after 4 cycles of chemotherapy but with residual mediastinal mass

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21
Q

Treatment of cystic adenomatoid malformation

A

Lobectomy

(segmentectomy –> prolonged air leak and other complications)

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22
Q

When would you operate on bronchogenic cysts?

A

Indications for treatment:

  • Increasing cyst size
  • Air/fluid level
  • Symptoms
  • Subcarinal cyst (cause obstruction)
  • Surgery = cyst excision (spare pulmonary tissue)
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23
Q

Extralobar vs. Intralobar sequestration

Presentation

Arterial supply

Venous drainage

Bronchial communication

Treatment

A

Extralobar presents in neonates with respiratory distress. intralobar presents in adolescence or young adulthood with cough, fever, sputum production Both have systemic arterial supply from aorta Extralobar venous drainage = systemic (azygous vein) Intralobar venous drainage = pulmonary vein Intralobar communicates with bronchial tree, extralobar does not Extralobar treated with simple excision and ligation of anomalous artery if lesion is compressing lung tissue and causing symptoms Intralobar treated with lobectomy during quiescent phase of illness (watch out for anomalous artery in inferior pulmonary ligament)

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24
Q

Bronchoalveolar carcinoma

A

Now called adenocarcinoma in situ in WHO classification May present as pneumonia-like infiltrate (or ground-glass) instead of a mass

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25
Q

EBUS accessible nodal stations

A

2, 3, 4, 7, 10, 11, 12

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26
Q

Chamberlain procedure-accessible nodal stations

A

5, 6

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27
Q

Lung cancer T1

A
  • Less than or equal to 3cm - Surrounded by lung or visceral pleura - No invasion proximal to lobar bronchus T1a = less than or equal to 2cm T1b = between 2 and 3cm
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28
Q

Lung cancer T2

A
  • Larger than 3cm but less than or equal to 7cm - Invades visceral pleura - Lobar atelectasis or obstructive pneumonitis - Involves main bronchus but not within 2cm of carina T2a = 3cm-5cm T2b = 5cm-7cm
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29
Q

Lung cancer T3

A
  • >7cm - Any size that invades chest wall (including superior sulcus/Pancoast), diaphragm, parietal or mediastinal pleura, pericardium, phrenic nerve - Atelectasis or obstructive pneumonia of entire lung - Within 2cm of carina but not involving carina - Separate tumor nodule(s) in same lobe
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30
Q

Lung cancer T4

A
  • Any size that invades mediastinum, heart, great vessels, esophagus, trachea, carina, vertebral body, recurrent laryngeal nerve - Satellite tumor nodules in a different ipsilateral lobe
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31
Q

Lung cancer N0

A

No nodal metastasis

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32
Q

Lung cancer N1

A
  • Peribronchial or ipsilateral hilar nodes (double digit stations, 10-14) - Includes involvement by direct extension into node
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33
Q

Lung cancer N2

A

Ipsilateral mediastinal or subcarinal nodes (single digit stations, 1-9) N2 disease = Stage IIIA, except for T4N2M0, which is IIIB

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34
Q

Lung cancer N3

A
  • Contralateral mediastinal or hilar nodes - Scalene or supraclavicular nodes (ipsilateral or contralateral)
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35
Q

Lung cancer M0

A

No distant metastasis

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36
Q

Lung cancer M1 (M1a and M1b)

A

Distant metastasis M1a = Separate tumor nodules in contralateral lung, pleural nodules, or malignant pleural or pericardial effusion M1b = Distant metastasis (most common = brain, bone, adrenals, liver)

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37
Q

Lung cancer inoperability based on TNM Staging

A
  • Supraclavicular or contralateral mediastinal nodes (N3) - Invasion of spine, esophagus, trachea, carina, aorta, or heart (T4) - Separate tumor nodules in different ipsilateral lobe (T4) - Separate tumor nodules in contralateral lung (M1a) - Malignant pleural/pericardial effusion (M1a) - Distant extrathoracic mets (M1b)
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38
Q

Management of N2 disease

A

Single station or multistation, non-bulky disease should get surgery after neoadjuvant therapy If N2 disease found at time of VATS resection, can abort for neoadjuvant therapy If N2 disease found at time of thoracotomy, continue surgical resection

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39
Q

Treatment of small cell lung cancer

A
  • Not treated surgically - Limited disease treated with chemoradiation - Extensive disease treated with chemotherapy
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40
Q

Predictors of metastasis vs. primary lung cancer in patients with lung nodule and other cancer

A

Almost always metastatic - melanoma, sarcoma, highly anaplastic carcinoma More likely lung primary if other primary is squamous cell Primary adenocarcinoma - could be either met or primary lung

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41
Q

Lymphangioleiomyomatosis

A
  • Of mesodermal origin - Present with spontaneous pneumothorax, chylothorax, hemoptysis, edema - Mild disease = cxr appears normal - Advanced disease = cxr shows honeycombing at bases, CT shows larger cystic changes - Treated with conservative resection when symptomatic
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42
Q

Lung neuroendocrine tumors

A

Progression of malignant potential: Typical carcinoid –> Atypical carcinoid –> Small cell undifferentiated carcinoma –> Large cell undifferentiated carcinoma –> Non-small cell carcinoma with neuroendocrine features

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43
Q

Division level for palmar-only hyperhidrosis

A

Top of 3rd or 4th rib (per STS consensus statement) -Top of 4th rib –> moister hands, but lower incidence of compensatory hyperhidrosis

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44
Q

Surgical margin for chest wall tumors

A

Full-thickness excision with one rib margin Chest wall mets and benign tumors - 2cm Osteogenic sarcoma and malignant fibrous histiocytoma - 4cm

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45
Q

Diaphragmatic openings

A

IVC = T8 Esophagus = T10 Aorta = T12

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46
Q

Diagnosis of mesothelioma

A

CXR - pleural effusion, pleural thickening, calcifications CT needed to define anatomy and extent of disease Need tissue biopsy to confirm diagnosis (not just fluid analysis) - Open or VATS surgical biopsy

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47
Q

Surgical treatment of chylothorax

A

Duct ligation in right hemithorax (mass ligation of tissue between azygous vein and aorta just above the diaphragm)

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48
Q

Management of congenital tracheal stenosis

A
  • Dilation will just cause split in trachea and form granulation tissue –> further narrowing - Resection –> tension, further stenosis - Perform tracheostomy at site of stenosis, with goal of palliation while the child grows and can later undergo a resection and anastomosis
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49
Q

Most common tracheal neoplasms

A

1 = squamous cell carcinoma #2 = adenoid cystic carcinoma

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50
Q

Location of blood supply to trachea

A

Lateral

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51
Q

Surgical approach for upper 1/2 tracheal lesions

A

Collar incision +/- sternal split - Cervical flexion is the most effective maneuver to allow for tracheal resection with primary repair (can stitch the chin to the chest) - Suprahyoid laryngeal release useful to gain additional 1.5cm of length - Intrapericardial release of the pulmonary vessels (more effective on right side because left mainstem bronchus tethered by aortic arch)

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52
Q

Surgical approach for lower 1/2 tracheal lesions

A

Posterolateral thoracotomy in 4th interspace - Can perform cervical flexion to get more length

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53
Q

Most common T-E Fistula

A

Esophageal atresia with distal T-E fistula

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54
Q

Surgical management of TE fistula

A

Incision dictated by aortic arch - left thoracotomy for right-sided arch, and vice versa -Divide fistula, repair both sides, leave tissue in place to buttress repair

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55
Q

Treatment of caustic esophageal ingestion

A
  • Dilution. No emesis - Fluids, antibiotics. - Intubation for airway protection - EGD. Stop when burn reached - Sepsis/full-thickness necrosis: cervical esophagostomy, gastrostomy, esophageal isolation (resection controversial)
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56
Q

Manometric findings in achalasia

A
  • Normal pharyngoesophageal junction activity - Absent peristalsis - Contractions weak and mirror-like at all levels - Weaker contractions with progressive dilatation - Normal or elevated LES pressure - Incomplete or absent LES relaxation
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57
Q

Manometric findings in diffuse esophageal spasm

A
  • Normal activity in pharyngoesophageal junction and proximal 1/3 of esophagus - Peristalsis >10% but
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58
Q

Treatment of esophageal diverticulum

A

Diverticulectomy and myotomy

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59
Q

Treatment of esophageal leiomyoma

A

Surgical enucleation if symptomatic

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60
Q

Esophageal cancer Tis

A

High-grade dysplasia

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61
Q

Esophageal cancer T1

A

Invades lamina propria, muscularis mucosa, or submucosa T1a = Invades lamina propria or muscularis mucosa T1b = Invades submucosa

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62
Q

Esophageal cancer T2

A

Invades muscularis propria

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63
Q

Esophageal cancer T3

A

Invades adventitia

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64
Q

Esophageal cancer T4

A

Invades adjacent structure T4a = invades pleura, pericardium, or diaphragm (resectable) T4b = invades other organs (aorta, spine, trachea); unresectable

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65
Q

Esophageal cancer N0

A

No nodal mets

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66
Q

Esophageal cancer N1

A

Mets in 1-2 regional lymph nodes

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67
Q

Esophageal cancer N2

A

Mets in 3-6 regional lymph nodes

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68
Q

Esophageal cancer N3

A

Mets in 7 or more regional lymph nodes

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69
Q

Blood supply to anterolateral papillary muscle

A

LAD and circumflex artery - Dual blood supply makes it much less susceptible to ischemic injury

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70
Q

Blood supply to posteromedial papillary muscle

A

Usually only supplied by PDA - Makes it more susceptible to ischemic injury and rupture

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71
Q

How to calculate ejection fraction

A

Stroke volume / end-diastolic volume

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72
Q

What mediates calcium entry into/exit from myocyte

A

Cyclic AMP

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73
Q

Mechanism of systolic heart failure

A

Reduced cardiac contractility

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74
Q

Mechanism of diastolic heart failure

A

Abnormal relaxation, increased chamber stiffness, chamber dilation

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75
Q

Mechanism of milrinone

A

Inhibits phosphodiesterase, which increases cyclic AMP

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76
Q

Mechanism of beta agonists

A

Activate G protein, which increases cyclic AMP

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77
Q

Most common cause of ATIII deficiency, and treatment

A

MCC = prior heparin exposure Treatment = FFP, ATIII concentrate

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78
Q

Mechanism of bivalirudin - Reversal - Clearance

A

Direct thrombin inhibitor - binds to the catalytic site and anion-binding exosite of circulating and clot-bound thrombin - No reversal agent, have to wait - Prolongs ACT, minimal effect on platelets - Renal excretion

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79
Q

Normal SVR

A

700-1500 dyn/cm^5

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80
Q

Normal A-a gradient

A

10-15 on room air

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81
Q

Effects of IABP inflating too early

A
  • Can cause premature closing of aortic valve - Can increase LVEDV, LVEDP, and PCWP - Can increase LV wall stress leading to increased afterload and myocardial oxygen demand
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82
Q

Effects of IABP inflating too late

A

Inadequate coronary artery perfusion

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83
Q

Effects of IABP deflating too early

A
  • Inadequate coronary artery perfusion - Potential for retrograde coronary and carotid blood flow - Increased myocardial oxygen demand
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84
Q

Effects of IABP deflating too late

A
  • Increased myocardial oxygen consumption (due to LV ejecting against greater resistance) - Increased afterload, LV outflow obstruction
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85
Q

Contraindications for IABP placement

A
  • Aortic insufficiency - Severe PVOD
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86
Q

Largest foreign surface contact area in the CPB circuit

A

The oxygenator

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87
Q

Goals for CPB flow

A
  • 2.2 L/m/m^2 for adults - 2.5 L/m/m^2 for infants/children - 1.8 - 2.0 L/m/m^2 for adults with BSA greater than 2 to avoid excessive flow through oxygenator - 1.7 L/m/m^2 is safe with moderate hypothermia - 1.0 L/m/m^2 is adequate for deep hypothermia
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88
Q

Alpha stat

A

Method for managing CPB/Deep hypothermic circ arrest - Don’t temperature correct the pH and pCO2. Set the standard at 37C and don’t correct as the patient gets cold. - So as they are cooled, the pH will go up and the actual pCO2 and pO2 will go down - Proponents argue that its better for maintenance of enzymatic function during hypothermia

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89
Q

pH stat

A

Method for managing CPB/Deep hypothermic circ arrest - Maintain the pH at 7.40 and the pCO2 at actual temperature. - Need to add CO2 to the inspired gas - So the “real” values will be a lower pH and a higher CO2 than the measured values - Increases cerebral blood flow (can cause cerebral hypertension and microembolisation)

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90
Q

7 variables more predictive of operative mortality after CABG

A
  • Older age - Female gender - Previous CABG - Urgency of operation - Depressed LV function - Left main disease - Increasing extent of coronary disease
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91
Q

1/5/10 year patency of IMA graft

A

95%/94%/85%

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92
Q

1/5/10 year patency of radial artery graft

A

90%/85-90%/unknown

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93
Q

1/5/10 year patency of saphenous vein graft

A

85-90%/75 %/50%

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94
Q

Indications for surgery with post-infarct LV aneurysm

A
  • Large aneurysm and angina - CHF - Recurrent V-Tach - Risk of late rupture (?)
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95
Q

Results of STICH Trial

A

1000 patients with CAD, EF

96
Q

Indications for surgery with post-infarct VSD

A

The presence of a VSD (all of them get an operation if they are surgical candidates) - Should be done urgently if hemodynamically instability or end-organ dysfunction - Can wait 2-3 weeks if completely stable

97
Q

Carpentier’s classification of MR

A

Type I - annular dilation with normal leaflet motion Type II - leaflet prolapse (excess leaflet motion) Type III - leaflet restriction/tethering (restricted leaflet motion) - Type IIIa - diastolic tethering (restricted opening) - Type IIIb - systolic tethering (restricted closing) Acute ischemic MR = Type II Chronic ischemic MR = usually Type I or Type IIIb

98
Q

Anatomic changes in MR

A
  • Increase in annular area - Displacement of posteromedial papillary muscle - Tethering/restriction of posterior leaflet into apex
99
Q

Most common site of MI that causes post-MI MR

A

Inferior MI - 20% of wall and septum from right-dominant circulation and single blood supply to posteromedial papillary muscle

100
Q

Indications for surgery with ischemic MR

A
  • Papillary muscle rupture = emergent operation - Acute MR post-MI = should operate (30% hospital mortality without an operation) - Chronic ischemic MR = operate when severe or concomitant with CABG
101
Q

Indications for combined coronary and carotid procedures

A

Severe CAD (unstable angina, left main disease, or 3-vessel disease with poor LV function) and symptomatic carotid stenosis

102
Q

Indications for staged operations for coronary and carotid disease

A
  • Significant 1, 2, or 3-vessel CAD requiring CABG and asymptomatic high-grade carotid stenosis - Actively symptomatic carotid artery stenosis with stable angina and adequate LV function
103
Q

Echo measurements in severe AS

A

Mean gradient > 40 mmHg Aortic valve area <1

104
Q

Echo measurements in severe aortic regurgitation

A

LV end-systolic diameter > 50mm LV end-diastolic diameter >70mm Vena contracta width > 6-7mm Fiber shortening

105
Q

Indications for operation for aortic stenosis

A
  • All patients with symptoms Asymptomatic patients with: - Severe AS and LVEF
106
Q

Indications for operation for aortic regurgitation

A
  • All symptomatic patients Asymptomatic patients with: - Severe AR and LVEF 50mm or LVEDD >65mm)
107
Q

Which mitral valve leaflet is larger

108
Q

Blood supply to posteromedial papillary muscle

109
Q

Blood supply to anterolateral papillary muscle

A

LAD and Circumflex arteries

110
Q

Indications for operation for mitral stenosis

A
  • Symptomatic patients with severe MS who are not candidates for or have failed percutaneous mitral balloon commissurotomy - Severe MS and undergoing other cardiac surgery
111
Q

Echo findings in severe mitral stenosis

A

PA systolic pressure >50 (Moderate is 30-50) Mean gradient >10 (moderate is 5-10) Valve area < 1cm^2 (moderate is 1-1.5)

112
Q

Indications for operation for mitral regurgitation

A
  • All symptomatic patients Asymptomatic patients with: - Severe MR and LV dysfunction (LVEF 30-60% and/or LVESD >40) - New onset a-fib or pulmonary hypertension (PA > 50mmHg) - Moderate or severe MR undergoing other cardiac surgery
113
Q

Mitral valve repair vs. replacement

A

Low-risk patients with ischemic MR have better survival after repair than replacement No survival benefit for repair over replacement in high-risk patients

114
Q

Mechanisms of LV rupture following mitral valve repair

A
  • Traction on the mitral annulus - Annular disruption from manual lifting after prosthetic ring in place - Posterior AV groove suture penetration - LV perforation after papillary muscle resection - AV groove perforation after calcium removal
115
Q

Boundaries of the triangle of Koch

A

Ostium of coronary sinus posteriorly, anterior-septal leaflet commissure, tendon of Todaro (connects valve of IVC ostium to central fibrous body) posteriorly - Contains AV Node - If pushed to only name one leaflet as the border, its the septal leaflet

116
Q

Indications for operation for TR

A
  • Severe TR undergoing left-sided valve surgery - Mild or greater TR at the time of left-sided valve surgery with tricuspid annular dilation or evidence of right heart failure - Symptomatic severe TR unresponsive to medical therapy
117
Q

Echo findings in severe Tricuspid stenosis

A
  • Gradient > 4mmHg - Valve area
118
Q

Indications for operation for Tricuspid stenosis

A
  • Severe TS at the time of operation for left-sided valve - Isolated symptomatic severe TS
119
Q

Rates of re-infection requiring re-operation with homograft/autograft/mechanical/stented bioprosthetic

A

Homograft = autograft = 1.5% Stented bioprosthetic = mechanical = 4%

120
Q

INR goals for mechanical valve replacements

A

Aortic = 2.5-3.0 Mitral = 3.0-3.5 Both = 3.5-4.0

121
Q

Most common organism in acute infective endocarditis

A

Staph. aureus

122
Q

Most common organisms in subacute infective endocarditis

A

Step viridans, enterococcus, staph epidermidis, gram negative coccobacillus

123
Q

Most common valve for endocarditis

A

Aortic (mitral if caused by staph aureus)

124
Q

Treatment of fungal endocarditis

A

Early surgical intervention - medical mortality nearly 100%

125
Q

Indications for operation for endocarditis

A

Absolute indications: - CHF due to valve dysfunction - Unstable valve prosthesis - Uncontrolled infection (ie persistent bacteremia, fungal endocarditis) - Relapse after optimal therapy (prosthetic valve) Relative indications: - Perivalvular extension of infection - Staph infection of prosthesis - Persistent fever (culture negative) - Large vegetation (>10mm) - Relapse after optimal therapy (native valve)

126
Q

Cell cycle phases

A

G0 –> G1 –> S –> G2 –> M

127
Q

Cell cycle phase in which DNA replication occurs

128
Q

Cell cycle phase in which cells increase in size

129
Q

Cell cycle phase in which cells divide

130
Q

Mechanism of alkylating agents

A

Directly damage DNA. Work in all phases of cell cycle - Examples: cylophosphamide, Ifosfamide,

131
Q

Mechanism of anti-tumor antibiotics

A

Inhibit DNA replication. Work in all phases of cell cycle - Examples: bleomycin, epirubicin

132
Q

Mechanism of topoisomerase inhibitors

A

Interfere with the topoisomerase enzyme, which separates DNA strands for replication during S phase - Examples: irinotecan, etoposide, doxorubicin, daunorubicin

133
Q

EGFR oncogene

A

Observed in adenocarcinoma and squamous cell carcinoma of the lung

134
Q

ErbB2/Neu oncogene

A

Expression is associated with reduced survival in esophageal adenocarcinoma

135
Q

Cyclin D1

A

Oncogene present in 64% of esophageal adenocarcinoma

136
Q

K-ras

A

Oncogene which can mutate sporadically in adeno, squamous, and large cell lung cancer

137
Q

Myc

A

Oncogene seen in small cell lung cancer

138
Q

Chromosome 3p deletion

A

Tumor suppressor gene - deletions seen in 100% of small cell lung cancers, >50% of non-small cell lung cancers, and 70% of esophageal cancers

139
Q

Rb

A

Tumor suppressor gene - inactivated in >90% of small cell cancers and 20-60% of non-small cell lung cancers

140
Q

p53

A

Tumor suppressor gene - inactivated in 70% of lung cancers and 50% of esophageal cancers. Seen in Barrett’s dysplasia

141
Q

FBN1

A

Gene associated with Marfan’s syndrome - Defective fibrillin metabolism causes medial necrosis - Chromosome 15 - Autosomal dominant 70%

142
Q

NOTCH-1

A

Gene associated with biscuspid aortic valve and calcific aortic valve disease - Chromosome 9

143
Q

GATA-4

A

Gene associated with ASD/VSD, AV cushion defects - Chromosome 8

144
Q

SCN5A

A

Gene associated with a defect in the alpha-subunit of type V sodium channel causing conduction system defects, long QT syndrome, Brugada syndrome, dilated cardiomyopathy - Chromosome 3

145
Q

CASS Trial

A

CABG vs. medical therapy (1985) - 780 patients randomized - No difference in survival between groups - Subgroup analysis of patients with decreased EF - 160 randomized to CABG vs. medical therapy - Found that patients with 3-vessel disease and reduced EF who had CABG had significantly better survival than those who did not

146
Q

VA Coronary Artery Bypass Surgery Cooperative Study Group

A

CABG vs. medical therapy (1984) - 686 patients randomized - Improved survival in high-risk patients with surgical therapy -Improved survival at 7 years in all patients with surgery vs. medical therapy, but no difference at 11 years

147
Q

European Coronary Surgery Study Group

A

CABG vs. medical therapy (1982) - 768 patients randomized - Improved survival in surgical arm overall, as well as in patients with 3-vessel disease or proximal LAD disease

148
Q

ACME Trial

A

PCI vs. medical therapy (1992) - 212 patients randomized with single-vessel disease - Improved symptoms and exercise tolerance in PCI group

149
Q

RITA-2 Trial

A

PCI vs. medical therapy (1997/2003) - 1018 patients randomized - No difference in long-term survival (although early survival data favored medical management) - PCI improved angina symptoms and exercise tolerance

150
Q

TACTICS TIMI Trial

A

PCI vs. medical therapy (ie early invasive vs. conservative management; 2001) - Randomized 2220 patients - More conservative patients met the composite end point of death, nonfatal MI, or rehospitalization for ACS - Conservative group also had a higher rate of death or nonfatal MI

151
Q

RITA-1 Trial

A

CABG vs. PCI (1993) - 1011 patients with 1-3 vessel disease randomized - No difference in survival - Decreased re-vascularization procedures and improved symptoms in CABG group

152
Q

ERACI Trial

A

CABG vs. PCI (1996) - 127 patients randomized - PCI patients had more angina and more re-interventions - No difference in mortality or MIs

153
Q

ERACI II Trial

A

CABG vs. PCI (with bare metal stenting) - 2001 - 450 patients randomized - Early outcomes: More MIs and deaths in CABG group, more reinterventions in PCI group - 5 year outcomes: No difference in survival, higher rate of MACE in PCI group (driven by reinterventions)

154
Q

GABI Trial

A

CABG vs. PCI (1994) - 359 patients randomized - CABG patients had more early MIs, PCI patients had more reinterventions and less freedom from angina

155
Q

EAST Trial

A

CABG vs. PCI (1994) - 392 patients randomized - No difference in survival - More reinterventions and angina in PCI group

156
Q

CABRI Trial

A

CABG vs. PCI (1995) - 1054 patients randomized - No difference in survival - PCI group had more reinterventions and more angina

157
Q

BARI Trial

A

CABG vs. PCI (1997) - 1829 patients randomized - 5-year mortality significantly lower in CABG group - Subgroup analysis showed survival difference in diabetic patients, no difference in non-diabetics

158
Q

ARTS Trial

A

CABG vs. PCI (with bare metal stenting) -2001 - 1205 patients randomized - No difference in survival or MI, or stroke - Increased reinterventions in PCI group

159
Q

SOS Trial

A

CABG vs. PCI (stenting) - 2002 - 988 randomized - Better survival in CABG group - Higher reintervention rate in PCI group

160
Q

ARTS II Trial

A

CABG vs. PCI (DES vs. BMS) - 2010 - Not randomized. Compared 607 DES patients with the historical cohorts from the ARTS I Trial - Higher rate of MACCE in DES group compared with CABG group, primarily related to stent thrombosis

161
Q

SYNTAX Trial

A

CABG vs. PCI (DES) - 2009 - Randomized 1800 patients with LM or 3V disease - MACCE higher in PCI group at 12 months, primarily from reintervention rate - 5-yr followup: Higher MACCE, MI, and reinterventions in PCI group. No difference in survival.

162
Q

Echo findings in Severe MR

A

Vena contracta width >0.69cm Enlarged LA and LV Reurgitant orifice area >0.39 cm^2

163
Q

Principles of management in AS

A
  • High filling pressures due to LVH (don’t let them get dry) - Avoid tachycardia - Need atrial kick for adequate preloading of LV
164
Q

Principles of management of AI

A
  • Decrease afterload - Keep HR high-normal (avoid bradycardia) - CHF common
165
Q

Principles of management of MS

A
  • Keep adequate preload - Need high LA pressure and volume to fill LV - Avoid tachycardia (need to maintain diastolic filling time)
166
Q

Principles of management of MR

A

-Vasodilation to improve forward flow - Normal to increased heart rate (avoid bradycardia) - Volume overload leads to CHF and pulmonary hypertension

167
Q

Most common cardiac tumor

A

Myxoma (benign)

168
Q

Most common locations for myxomas

A

Left atrium (75%), right atrium (20%), ventricles (5%)

169
Q

Management of myxomas

A
  • All of these should be surgically removed - Transatrial vs. trans-septal - Minimal tumor manipulation (can embolize)
170
Q

Most common neoplastic process involving the heart

A

Metastatic tumors

171
Q

Carcinoid heart disease

A
  • Occurs in 50% of patients with carcinoid syndrome - Pathologic lesions (glistening, white-yellow fibrous deposits) on right-sided valves
172
Q

Inheritance pattern of hypertrophic cardiomyopathy

A

Autosomal dominant

173
Q

Echo findings in HOCM

A

LVOT obstruction Early aortic valve closure Small LV cavity Systolic anterior motion

174
Q

Cath findings in HOCM

A
  • LVOT obstruction - Increased LVEDP - Brockenbrough sign (Higher gradient, and thus lower-pressure beat following a PVC. Normally would expect high pressure beat following PVC due to more filling time and Frank-Starling curve effect) - Dynamic LVOT gradient (increases with exercise/provocation)
175
Q

Risk factors for sudden cardiac death in HOCM

A
  • Resting peak gradient >30mmHg - Young age - Syncope - Family history - Myocardial ischemia - Sustained VT on testing - VT on ambulatory monitoring
176
Q

Indications for operation in HOCM

A
  • NYHA Class III/IV - Symptoms not relieved by medical treatment - Gradient > 50mmHg (resting or provocative) - Atrial fibrillation
177
Q

Surgical options for HOCM

A
  • Myotomy, myomectomy - LV-aortic conduit - MVR - Myomectomy and MVR - DDD pacemaker - AICD - Percutaneous transluminal septal myocardial ablation - Cardiac transplantation
178
Q

Pulsus paradoxus

A

Decrease in systolic BP >10mmHg during inspiration - Decrease of less than 10 is normal - Mechanism: inspiration –> increase in negative intrathoracic pressure –> pulmonary vasodilation –> decreased pulmonary venous return –> reduced left-heart filling –> reduced stroke volume –> decrease in systolic blood pressure - Pressure equalization during cardiac tamponade means that the increased right sided volume and decreased left sided volume during inspiration allows the right ventricle to compress the left ventricle and further decrease stroke volume and systolic BP

179
Q

Relationship of subclavian vessles to anterior scalene muscle

A

Vein is anterior, artery is posterior

180
Q

PA branch most at risk for injury during lobectomy

A

Anterior branch of left PA

181
Q

Indications for lung cancer screening with low-dose CT scan

A

55-74 years old >30 pack-year smoking history If quit smoking, quit less than 15 years prior

182
Q

Size cutoff for mass vs. nodule

A

Mass = lesion > 3cm, nodule =

183
Q

Treatment of superior sulcus tumors

A

Neoadjuvant chemoradiation followed by surgical resection

184
Q

Most common lung cancer associated with SIADH

A

Small cell

185
Q

Most common lung cancer associated with hypercalcemia

A

Squamous cell

186
Q

Most common lobe to get lung cancer

A

Right upper lobe

187
Q

Cath findings in chronic constrictive pericarditis

A

Square root sign = seen on ventricular pressure waveform during diastole. Rapid descent at beginning of diastole followed by rapid rise and then plateau Equalization of chamber pressures

188
Q

Surgical approach for pericardiectomy

A

Sternotomy for RV access Left thoracotomy better for LV access Decorticate left ventricle first (so you don’t go into heart failure)

189
Q

Most specific predictor of complications following lung resection

A

Maximum oxygen consumption during exercise (VO2max)

190
Q

Indications for pre-op PFTs

A
  • Pt with history of smoking or dyspnea undergoing cardiothoracic or upper abdominal surgery - Pt with unexplained dyspnea or pulmonary symptoms undergoing head, neck, orthopedic, or lower abdominal surgery - Any pt undergoing a lung resection
191
Q

Determining risk of post-op complications following lung resection

A
  • If pred postop FEV1 and DLCO both >60%, pt is low risk - If pred postop FEV1 or DLCO are between 30-60%, perform exercise test. If pt passes, they are intermediate risk - If pred postop FEV1 or DLCO is
192
Q

Mechanism for decompensation with cardiac herniation on each side following pneumonectomy

A

Left: LV herniates through pericardial defect and strangulates, leading to impairment of diastole, systole, and coronary perfusion. Right: Torsion of the RV leads to occlusion of inflow from the SVC and IVC

193
Q

Bronchopleural fistula most commonly seen after which type of pneumonectomy?

A

Right pneumonectomy for infection. Right side has longer bronchial stump, which can lead to pooling of airway secretions

194
Q

Principles of lung resection for carcinoid

A
  • Parenchymal-sparing resections are favored - R0 resection is critical - Lymph node assessment should be performed
195
Q

Adenoid cystic carcinomas of the lung

A
  • Highly radiosensitive - 10-year survival is 40% - Should obtain frozen section at time of resection - Don’t need to keep resecting to obtain negative margins
196
Q

Management of suspected chondrosarcoma

A
  • No incisional biopsy - No radio or chemo-sensitive - FNA accurate So if you suspect chondrosarcoma, need to resect with 5cm margins and perform chest wall reconstruction when indicated
197
Q

Doubling times for lung masses (Infectious, benign, malignant)

A
  • Infectious: 10 days, 450 days
198
Q

Contraindications to lung transplantation

A
  • History of malignancy within last 5 years - Uncorrectable coronary artery disease - Significant LV dysfunction - Renal failure - Active tobacco use
199
Q

Most common class of organism in lung abscess

A

Anaerobic bacteria

200
Q

How much pleural fluid is produced per day in healthy adults

201
Q

Triglyceride level diagnostic for chylothorax

202
Q

Management of suspected chondrosarcoma

A
  • No incisional biopsy - No radio or chemo-sensitive - FNA accurate So if you suspect chondrosarcoma, need to resect with 5cm margins and perform chest wall reconstruction when indicated
203
Q

Treatment of catemenial pneumothorax

A

Chest tube placement, pleurodesis, resection of endometrial implants, closure of porous diaphragmatic defects (primarily with mesh)

204
Q

Best test to work up dysphagia in a patient with a history of aspiration

A

Barium swallow

205
Q

Treatment of small cell tumor of the esophagus

A

Need to be aggressive. In young, functional patients, do radical esophagectomy and adjuvant chemoradiation.

206
Q

Treatment of nutcracker esophagus and diffuse esophageal spasm

A

Medical therapy with nitrates

207
Q

PRA Cutoffs

A

>10% - get a crossmatch >25% - high risk Management of high PRA levels: Plasmapheresis IVIG Cyclophosphamide Rituximab Photopheresis Total bone marrow irradiation

208
Q

Survival following heart transplantation

A

81% at 1 year, 4% yearly mortality after that

209
Q

Survival following lung transplantation

A

Single: 71% at 1 year, 45% at 5 years Double: 72% at 1 year, 50% at 5 years

210
Q

Indications for ICD placement in heart failure

A

LVEF 40 days post-MI, with NYHA II/III NICM and EF

211
Q

Guidelines for repair of ascending aortic aneurysms

A

Isolated and asymptomatic - 5.5cm Marfan/connective tissue disorder - 4.5cm Concomitant valve operation - 4.5cm Growth rate > 0.5cm/yr Any size symptomatic

212
Q

Guidelines for repair of descending aortic aneurysms

A

Thoracoabdominal - 6cm Chronic dissection - 5.5cm Degenerative or traumatic - endovascular repair

213
Q

Management of intramural hematoma and penetrating atherosclerotic ulcer

A

Treat like dissection, high risk of rupture (35% in IMH, 42% in PAU) Operate early

214
Q

Trusler’s Rule

A

To determine the circumference of a PA Band Simple defect (ie VSD): 20mm + wt (kg) Mixing defect (ie transposition): 24mm + wt (kg) Goal is to get the PA pressure to be 30-50% systolic and O2 sat 85-90% on 50% fiO2

215
Q

Timing of aortic coarctation repair

A

If in heart failure, operate at time of diagnosis If no heart failure or failure to thrive, operate at 3-6 months - There is an increased incidence of mortality recurrent stenosis if you operate before 3 months of age

216
Q

Scimitar syndrome

A

Anomalous right pulmonary venous return into IVC (drains entire right lung) - Enters at or below the IVC-RA junction Associated with right lung, cardiac, and diaphragm abnormalities

217
Q

Traction vs. pulsion diverticula

A

Pulsion - form from high intraluminal pressure at site of weakness in the wall - False diverticulum - Zencker’s is an example of this Traction - form from pulling forces on the outside of the esophageal wall from inflammatory process - True diverticulum

218
Q

False negative rate for PET-CT to evaluate N2 disease in lung cancer

219
Q

Which levels should be divided for palmar hyperhidrosis?

A

R3 and R4 (the pleura overlying the 3rd and 4th ribs) For facial hyperhidrosis, divide R2 chain, for axillary divide R4 and R5 Also divide the pleura 2-3cm lateral to the chain to take any branches

220
Q

Where is there a risk of injury to circumflex artery during mitral valve surgery

A

Posteromedially (on the left/medial side of the posterior annulus)

221
Q

Structure that prevents RV distention in PE/MI

A

Moderator band

222
Q

Goals of therapy in medical management of mechanical complications of acute MI

A

Afterload reduction and inotropes

223
Q

Rate of stroke in CABG patients with no significant carotid stenosis

224
Q

Carotid artery stenting vs. endarterectomy

A

Higher risk of stroke with stenting, higher risk of MI with endarterectomy. No difference in the composite outcome of stroke, MI, or death between groups

225
Q

Life expectancy in untreated AS by symptoms

A

Angina - 5 years Syncope - 3 years Heart failure - 2 years

226
Q

Location of at-risk structures during AVR

A

Anterior mitral leaflet - beneath non and left coronary cusps Membranous septum - beneath non and right coronary cusps Bundle of His (Conduction system) - beneath the commissure between the non and right coronary cusps

227
Q

Options for AVR in women who want to have children

A

Ross procedure or bioprosthetic valve with plans for mechanical valve later when it degenerates. Can’t get mechanical valve due to need for coumadin, which would be contraindicated in pregnancy

228
Q

Placement of sutures in tricuspid valve replacement

A

Deep sutures in the AV nodal region (have to put some sutures in, otherwise will have paravalvular leak). If you take shallow bites, will disrupt conduction system

229
Q

Heart block after mitral surgery

A

Injury to AV node and AV nodal artery with deep suture bites along the anterior leaflet of the mitral valve near the posteromedial commissure

230
Q

Mitral valve exposure with potential injury to sinus node artery

A

Trans-septal approach through the right atrium

231
Q

Prevention of and risk factors for AV groove dissociation

A

Risk factors: Extensive calcification of posterior mitral valve leaflet and annulus, lifting the heart after MVR, vigorous debridement of the posterior leaflet Prevention: posterior leaflet preservation, chordal-sparing techniques. 50% mortality

232
Q

Most common cause of mitral stenosis

A

Rheumatic fever

233
Q

Most common organism in prosthetic valve endocarditis

A

Coagulase-negative staphylococcus

234
Q

Types of thoracoabdominal aneurysms

A

Type I: Origin of left subclavian to suprarenal abdominal aorta Type II: Left subclavian to aortic bifurcation Type III: Distal thoracic aorta (ie level of diaphragm) to aortic bifurcation Type IV: Exclusively below diaphragm

235
Q

Indications for AICD in heart failure patients

A

Must meet these criteria: - At least 40 days after MI - EF 35% or less - NYHA II or III symptoms - Expected survival > 1 year

2021 September TSITE Review (1 decks)

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