Thoracic Surgery Flashcards
1
Q
Boundaries of cervicoaxillary canal
A
First rib inferiorly
Clavicle superiorly
Costoclavicular ligament medially
2
Q
Layers 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)
3
Q
Normal Demeester Score
A
Less than 14.72
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
5
Q
Incision for innominate artery injury
A
Sternotomy
6
Q
Incision for proximal right common carotid artery injury
A
Sternotomy
7
Q
Incision for proximal right subclavian artery injury
A
Sternotomy
8
Q
Incision for distal carotid artery injury
A
Supraclavicular or anterior SCM
9
Q
Incision for distal subclavian/axillary artery injury
A
Infraclavicular
10
Q
Incision for proximal leftsubclavian artery injury
A
Left posterolateral thoracotomy or trapdoor
11
Q
Management of traumatic coronary artery injury
A
If cardiac dysfunction, initiate CPB and repair/bypass the artery
12
Q
Indications for VATS in thoracic trauma
A
- Ongoing hemorrhage
- Retained hemothorax
- Persistent pneumothorax
- Diagnosis and treatment of diaphragmatic injury
- Pericardial window for relief of cardiac tamponade
- Management of thoracic duct injuries
- Treatment of post-trauma empyema
- Removal of foreign bodies
13
Q
NETT trial for LVRS
A
Survival benefit in surgical arm for patients with heterogenous disease (upper-lobe predominant)
Patients whose emphysema was predominantly in the upper lobes and whose exercise capacity was low after pulmonary rehabilitation were more likely to function better two years after the surgery then those who received only medical therapy. These patients also appear to have a survival advantage with LVRS.
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
Operation of choice is lobectomy
15
Q
Most common organism in postpneumonectomy empyema
A
Staph aureus
If polymicrobial, this suggests enteropleural fistula
16
Q
Management of early post-op BP fistula (
A
Return to OR, resuture bronchus, cover with muscle flap
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 5% for simple aspergilloma, 33% for complex aspergilloma)
18
Q
Indications for surgery in TB
A
- Persistently positive sputum cultures with cavitation after 5-6 months of continuous optimal medical therapy with 2 or more drugs
- Localized pulmonary disease caused by MAI, TB, or other atypical mycobacterium which is drug-resistant
- Mass lesion of the lung in area of TB involvement
- Life-threatening or recurrent severe hemoptysis
- BP fistula in association with mycobacterial infection that doesn’t respond to chest tube
19
Q
Treatment of seminomatous germ cell mediastinal tumors
A
Radiation +/- cisplatin-based chemotherapy
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
21
Q
Treatment of cystic adenomatoid malformation
A
Lobectomy (segmentectomy –> prolonged air leak and other complications)
22
Q
Management of bronchogenic cysts
A
Indications for treatment:
- Increasing cyst size
- Air/fluid level
- Symptoms
- Subcarinal cyst (cause obstruction)
Surgery = cyst excision (spare pulmonary tissue)
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)
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
25
EBUS accessible nodal stations
2, 3, 4, 7, 10, 11, 12
26
Chamberlain procedure-accessible nodal stations
5, 6
27
Lung cancer T1
- 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
```
28
Lung cancer T2
- 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
```
29
Lung cancer T3
- >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
30
Lung cancer T4
- Any size that invades mediastinum, heart, great vessels, esophagus, trachea, carina, vertebral body, recurrent laryngeal nerve
- Satellite tumor nodules in a different ipsilateral lobe
31
Lung cancer N0
No nodal metastasis
32
Lung cancer N1
- Peribronchial or ipsilateral hilar nodes (double digit stations, 10-14)
- Includes involvement by direct extension into node
33
Lung cancer N2
Ipsilateral mediastinal or subcarinal nodes (single digit stations, 1-9)
N2 disease = Stage IIIA, except for T4N2M0, which is IIIB
34
Lung cancer N3
- Contralateral mediastinal or hilar nodes
| - Scalene or supraclavicular nodes (ipsilateral or contralateral)
35
Lung cancer M0
No distant metastasis
36
Lung cancer M1 (M1a and M1b)
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)
37
Lung cancer inoperability based on TNM Staging
- 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)
38
Management of N2 disease
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
39
Treatment of small cell lung cancer
- Not treated surgically
- Limited disease treated with chemoradiation
- Extensive disease treated with chemotherapy
40
Predictors of metastasis vs. primary lung cancer in patients with lung nodule and other cancer
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
41
Lymphangioleiomyomatosis
- 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
42
Lung neuroendocrine tumors
Progression of malignant potential:
Typical carcinoid --> Atypical carcinoid --> Small cell undifferentiated carcinoma --> Large cell undifferentiated carcinoma --> Non-small cell carcinoma with neuroendocrine features
43
Division level for palmar-only hyperhidrosis
Top of 3rd or 4th rib (per STS consensus statement)
-Top of 4th rib --> moister hands, but lower incidence of compensatory hyperhidrosis
44
Surgical margin for chest wall tumors
Full-thickness excision with one rib margin
Chest wall mets and benign tumors - 2cm
Osteogenic sarcoma and malignant fibrous histiocytoma - 4cm
45
Diaphragmatic openings
```
IVC = T8
Esophagus = T10
Aorta = T12
```
46
Diagnosis of mesothelioma
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
47
Surgical treatment of chylothorax
Duct ligation in right hemithorax (mass ligation of tissue between azygous vein and aorta just above the diaphragm)
48
Management of congenital tracheal stenosis
- 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
49
Most common tracheal neoplasms
#1 = squamous cell carcinoma
#2 = adenoid cystic carcinoma
50
Location of blood supply to trachea
Lateral
51
Surgical approach for upper 1/2 tracheal lesions
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)
52
Surgical approach for lower 1/2 tracheal lesions
Posterolateral thoracotomy in 4th interspace
- Can perform cervical flexion to get more length
53
Most common T-E Fistula
Esophageal atresia with distal T-E fistula
54
Surgical management of TE fistula
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
55
Treatment of caustic esophageal ingestion
- 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)
56
Manometric findings in achalasia
- 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
57
Manometric findings in diffuse esophageal spasm
- Normal activity in pharyngoesophageal junction and proximal 1/3 of esophagus
- Peristalsis >10% but
58
Treatment of esophageal diverticulum
Diverticulectomy and myotomy
59
Treatment of esophageal leiomyoma
Surgical enucleation if symptomatic
60
Esophageal cancer Tis
High-grade dysplasia
61
Esophageal cancer T1
Invades lamina propria, muscularis mucosa, or submucosa
```
T1a = Invades lamina propria or muscularis mucosa
T1b = Invades submucosa
```
62
Esophageal cancer T2
Invades muscularis propria
63
Esophageal cancer T3
Invades adventitia
64
Esophageal cancer T4
Invades adjacent structure
```
T4a = invades pleura, pericardium, or diaphragm (resectable)
T4b = invades other organs (aorta, spine, trachea); unresectable
```
65
Esophageal cancer N0
No nodal mets
66
Esophageal cancer N1
Mets in 1-2 regional lymph nodes
67
Esophageal cancer N2
Mets in 3-6 regional lymph nodes
68
Esophageal cancer N3
Mets in 7 or more regional lymph nodes
69
Blood supply to anterolateral papillary muscle
LAD and circumflex artery
| - Dual blood supply makes it much less susceptible to ischemic injury
70
Blood supply to posteromedial papillary muscle
Usually only supplied by PDA
| - Makes it more susceptible to ischemic injury and rupture
71
How to calculate ejection fraction
Stroke volume / end-diastolic volume
72
What mediates calcium entry into/exit from myocyte
Cyclic AMP
73
Mechanism of systolic heart failure
Reduced cardiac contractility
74
Mechanism of diastolic heart failure
Abnormal relaxation, increased chamber stiffness, chamber dilation
75
Mechanism of milrinone
Inhibits phosphodiesterase, which increases cyclic AMP
76
Mechanism of beta agonists
Activate G protein, which increases cyclic AMP
77
Most common cause of ATIII deficiency, and treatment
```
MCC = prior heparin exposure
Treatment = FFP, ATIII concentrate
```
78
Mechanism of bivalirudin
- Reversal
- Clearance
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
79
Normal SVR
700-1500 dyn/cm^5
80
Normal A-a gradient
10-15 on room air
81
Effects of IABP inflating too early
- 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
82
Effects of IABP inflating too late
Inadequate coronary artery perfusion
83
Effects of IABP deflating too early
- Inadequate coronary artery perfusion
- Potential for retrograde coronary and carotid blood flow
- Increased myocardial oxygen demand
84
Effects of IABP deflating too late
- Increased myocardial oxygen consumption (due to LV ejecting against greater resistance)
- Increased afterload, LV outflow obstruction
85
Contraindications for IABP placement
- Aortic insufficiency
| - Severe PVOD
86
Largest foreign surface contact area in the CPB circuit
The oxygenator
87
Goals for CPB flow
- 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
88
Alpha stat
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
89
pH stat
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)
90
7 variables more predictive of operative mortality after CABG
- Older age
- Female gender
- Previous CABG
- Urgency of operation
- Depressed LV function
- Left main disease
- Increasing extent of coronary disease
91
1/5/10 year patency of IMA graft
95%/94%/85%
92
1/5/10 year patency of radial artery graft
90%/85-90%/unknown
93
1/5/10 year patency of saphenous vein graft
85-90%/75 %/50%
94
Indications for surgery with post-infarct LV aneurysm
- Large aneurysm and angina
- CHF
- Recurrent V-Tach
- Risk of late rupture (?)
95
Results of STICH Trial
1000 patients with CAD, EF
96
Indications for surgery with post-infarct VSD
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
Carpentier's classification of MR
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
Anatomic changes in MR
- Increase in annular area
- Displacement of posteromedial papillary muscle
- Tethering/restriction of posterior leaflet into apex
99
Most common site of MI that causes post-MI MR
Inferior MI
| - 20% of wall and septum from right-dominant circulation and single blood supply to posteromedial papillary muscle
100
Indications for surgery with ischemic MR
- 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
Indications for combined coronary and carotid procedures
Severe CAD (unstable angina, left main disease, or 3-vessel disease with poor LV function) and symptomatic carotid stenosis
102
Indications for staged operations for coronary and carotid disease
- 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
Echo measurements in severe AS
Mean gradient > 40 mmHg
| Aortic valve area <1
104
Echo measurements in severe aortic regurgitation
LV end-systolic diameter > 50mm
LV end-diastolic diameter >70mm
Vena contracta width > 6-7mm
Fiber shortening
105
Indications for operation for aortic stenosis
- All patients with symptoms
Asymptomatic patients with:
- Severe AS and LVEF
106
Indications for operation for aortic regurgitation
- All symptomatic patients
Asymptomatic patients with:
- Severe AR and LVEF 50mm or LVEDD >65mm)
107
Which mitral valve leaflet is larger
Posterior
108
Blood supply to posteromedial papillary muscle
RCA/PDA
109
Blood supply to anterolateral papillary muscle
LAD and Circumflex arteries
110
Indications for operation for mitral stenosis
- 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
Echo findings in severe mitral stenosis
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
Indications for operation for mitral regurgitation
- 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
Mitral valve repair vs. replacement
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
Mechanisms of LV rupture following mitral valve repair
- 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
Boundaries of the triangle of Koch
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
Indications for operation for TR
- 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
Echo findings in severe Tricuspid stenosis
- Gradient > 4mmHg
| - Valve area
118
Indications for operation for Tricuspid stenosis
- Severe TS at the time of operation for left-sided valve
| - Isolated symptomatic severe TS
119
Rates of re-infection requiring re-operation with homograft/autograft/mechanical/stented bioprosthetic
Homograft = autograft = 1.5%
Stented bioprosthetic = mechanical = 4%
120
INR goals for mechanical valve replacements
```
Aortic = 2.5-3.0
Mitral = 3.0-3.5
Both = 3.5-4.0
```
121
Most common organism in acute infective endocarditis
Staph. aureus
122
Most common organisms in subacute infective endocarditis
Step viridans, enterococcus, staph epidermidis, gram negative coccobacillus
123
Most common valve for endocarditis
Aortic (mitral if caused by staph aureus)
124
Treatment of fungal endocarditis
Early surgical intervention - medical mortality nearly 100%
125
Indications for operation for endocarditis
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
Cell cycle phases
G0 --> G1 --> S --> G2 --> M
127
Cell cycle phase in which DNA replication occurs
S
128
Cell cycle phase in which cells increase in size
G1
129
Cell cycle phase in which cells divide
M
130
Mechanism of alkylating agents
Directly damage DNA. Work in all phases of cell cycle
- Examples: cylophosphamide, Ifosfamide,
131
Mechanism of anti-tumor antibiotics
Inhibit DNA replication. Work in all phases of cell cycle
- Examples: bleomycin, epirubicin
132
Mechanism of topoisomerase inhibitors
Interfere with the topoisomerase enzyme, which separates DNA strands for replication during S phase
- Examples: irinotecan, etoposide, doxorubicin, daunorubicin
133
EGFR oncogene
Observed in adenocarcinoma and squamous cell carcinoma of the lung
134
ErbB2/Neu oncogene
Expression is associated with reduced survival in esophageal adenocarcinoma
135
Cyclin D1
Oncogene present in 64% of esophageal adenocarcinoma
136
K-ras
Oncogene which can mutate sporadically in adeno, squamous, and large cell lung cancer
137
Myc
Oncogene seen in small cell lung cancer
138
Chromosome 3p deletion
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
Rb
Tumor suppressor gene - inactivated in >90% of small cell cancers and 20-60% of non-small cell lung cancers
140
p53
Tumor suppressor gene - inactivated in 70% of lung cancers and 50% of esophageal cancers. Seen in Barrett's dysplasia
141
FBN1
Gene associated with Marfan's syndrome
- Defective fibrillin metabolism causes medial necrosis
- Chromosome 15
- Autosomal dominant 70%
142
NOTCH-1
Gene associated with biscuspid aortic valve and calcific aortic valve disease
- Chromosome 9
143
GATA-4
Gene associated with ASD/VSD, AV cushion defects
| - Chromosome 8
144
SCN5A
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
CASS Trial
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
VA Coronary Artery Bypass Surgery Cooperative Study Group
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
European Coronary Surgery Study Group
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
ACME Trial
PCI vs. medical therapy (1992)
- 212 patients randomized with single-vessel disease
- Improved symptoms and exercise tolerance in PCI group
149
RITA-2 Trial
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
TACTICS TIMI Trial
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
RITA-1 Trial
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
ERACI Trial
CABG vs. PCI (1996)
- 127 patients randomized
- PCI patients had more angina and more re-interventions
- No difference in mortality or MIs
153
ERACI II Trial
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
GABI Trial
CABG vs. PCI (1994)
- 359 patients randomized
- CABG patients had more early MIs, PCI patients had more reinterventions and less freedom from angina
155
EAST Trial
CABG vs. PCI (1994)
- 392 patients randomized
- No difference in survival
- More reinterventions and angina in PCI group
156
CABRI Trial
CABG vs. PCI (1995)
- 1054 patients randomized
- No difference in survival
- PCI group had more reinterventions and more angina
157
BARI Trial
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
ARTS Trial
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
SOS Trial
CABG vs. PCI (stenting) - 2002
- 988 randomized
- Better survival in CABG group
- Higher reintervention rate in PCI group
160
ARTS II Trial
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
SYNTAX Trial
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
Echo findings in Severe MR
Vena contracta width >0.69cm
Enlarged LA and LV
Reurgitant orifice area >0.39 cm^2
163
Principles of management in AS
- High filling pressures due to LVH (don't let them get dry)
- Avoid tachycardia
- Need atrial kick for adequate preloading of LV
164
Principles of management of AI
- Decrease afterload
- Keep HR high-normal (avoid bradycardia)
- CHF common
165
Principles of management of MS
- Keep adequate preload
- Need high LA pressure and volume to fill LV
- Avoid tachycardia (need to maintain diastolic filling time)
166
Principles of management of MR
- Vasodilation to improve forward flow
- Normal to increased heart rate (avoid bradycardia)
- Volume overload leads to CHF and pulmonary hypertension
167
Most common cardiac tumor
Myxoma (benign)
168
Most common locations for myxomas
Left atrium (75%), right atrium (20%), ventricles (5%)
169
Management of myxomas
- All of these should be surgically removed
- Transatrial vs. trans-septal
- Minimal tumor manipulation (can embolize)
170
Most common neoplastic process involving the heart
Metastatic tumors
171
Carcinoid heart disease
- Occurs in 50% of patients with carcinoid syndrome
| - Pathologic lesions (glistening, white-yellow fibrous deposits) on right-sided valves
172
Inheritance pattern of hypertrophic cardiomyopathy
Autosomal dominant
173
Echo findings in HOCM
LVOT obstruction
Early aortic valve closure
Small LV cavity
Systolic anterior motion
174
Cath findings in HOCM
- 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
Risk factors for sudden cardiac death in HOCM
- Resting peak gradient >30mmHg
- Young age
- Syncope
- Family history
- Myocardial ischemia
- Sustained VT on testing
- VT on ambulatory monitoring
176
Indications for operation in HOCM
- NYHA Class III/IV
- Symptoms not relieved by medical treatment
- Gradient > 50mmHg (resting or provocative)
- Atrial fibrillation
177
Surgical options for HOCM
- Myotomy, myomectomy
- LV-aortic conduit
- MVR
- Myomectomy and MVR
- DDD pacemaker
- AICD
- Percutaneous transluminal septal myocardial ablation
- Cardiac transplantation
178
Pulsus paradoxus
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
Relationship of subclavian vessles to anterior scalene muscle
Vein is anterior, artery is posterior
180
PA branch most at risk for injury during lobectomy
Anterior branch of left PA
181
Indications for lung cancer screening with low-dose CT scan
55-74 years old
>30 pack-year smoking history
If quit smoking, quit less than 15 years prior
182
Size cutoff for mass vs. nodule
Mass = lesion > 3cm, nodule =
183
Treatment of superior sulcus tumors
Neoadjuvant chemoradiation followed by surgical resection
184
Most common lung cancer associated with SIADH
Small cell
185
Most common lung cancer associated with hypercalcemia
Squamous cell
186
Most common lobe to get lung cancer
Right upper lobe
187
Cath findings in chronic constrictive pericarditis
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
Surgical approach for pericardiectomy
Sternotomy for RV access
Left thoracotomy better for LV access
Decorticate left ventricle first (so you don't go into heart failure)
189
Most specific predictor of complications following lung resection
Maximum oxygen consumption during exercise (VO2max)
190
Indications for pre-op PFTs
- 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
Determining risk of post-op complications following lung resection
- 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
Mechanism for decompensation with cardiac herniation on each side following pneumonectomy
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
Bronchopleural fistula most commonly seen after which type of pneumonectomy?
Right pneumonectomy for infection. Right side has longer bronchial stump, which can lead to pooling of airway secretions
194
Principles of lung resection for carcinoid
- Parenchymal-sparing resections are favored
- R0 resection is critical
- Lymph node assessment should be performed
195
Adenoid cystic carcinomas of the lung
- 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
Management of suspected chondrosarcoma
- 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
Doubling times for lung masses (Infectious, benign, malignant)
- Infectious: 10 days, 450 days
198
Contraindications to lung transplantation
- History of malignancy within last 5 years
- Uncorrectable coronary artery disease
- Significant LV dysfunction
- Renal failure
- Active tobacco use
199
Most common class of organism in lung abscess
Anaerobic bacteria
200
How much pleural fluid is produced per day in healthy adults
1cc
201
Triglyceride level diagnostic for chylothorax
>110mg/dL
202
Management of suspected chondrosarcoma
- 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
Treatment of catemenial pneumothorax
Chest tube placement, pleurodesis, resection of endometrial implants, closure of porous diaphragmatic defects (primarily with mesh)
204
Best test to work up dysphagia in a patient with a history of aspiration
Barium swallow
205
Treatment of small cell tumor of the esophagus
Need to be aggressive. In young, functional patients, do radical esophagectomy and adjuvant chemoradiation.
206
Treatment of nutcracker esophagus and diffuse esophageal spasm
Medical therapy with nitrates
207
PRA Cutoffs
>10% - get a crossmatch
>25% - high risk
```
Management of high PRA levels:
Plasmapheresis
IVIG
Cyclophosphamide
Rituximab
Photopheresis
Total bone marrow irradiation
```
208
Survival following heart transplantation
81% at 1 year, 4% yearly mortality after that
209
Survival following lung transplantation
Single: 71% at 1 year, 45% at 5 years
Double: 72% at 1 year, 50% at 5 years
210
Indications for ICD placement in heart failure
LVEF 40 days post-MI, with NYHA II/III
NICM and EF
211
Guidelines for repair of ascending aortic aneurysms
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
Guidelines for repair of descending aortic aneurysms
Thoracoabdominal - 6cm
Chronic dissection - 5.5cm
Degenerative or traumatic - endovascular repair
213
Management of intramural hematoma and penetrating atherosclerotic ulcer
Treat like dissection, high risk of rupture (35% in IMH, 42% in PAU)
Operate early
214
Trusler's Rule
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
Timing of aortic coarctation repair
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
Scimitar syndrome
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
Traction vs. pulsion diverticula
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
False negative rate for PET-CT to evaluate N2 disease in lung cancer
5%
219
Which levels should be divided for palmar hyperhidrosis?
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
Where is there a risk of injury to circumflex artery during mitral valve surgery
Posteromedially (on the left/medial side of the posterior annulus)
221
Structure that prevents RV distention in PE/MI
Moderator band
222
Goals of therapy in medical management of mechanical complications of acute MI
Afterload reduction and inotropes
223
Rate of stroke in CABG patients with no significant carotid stenosis
<2%
224
Carotid artery stenting vs. endarterectomy
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
Life expectancy in untreated AS by symptoms
Angina - 5 years
Syncope - 3 years
Heart failure - 2 years
226
Location of at-risk structures during AVR
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
Options for AVR in women who want to have children
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
Placement of sutures in tricuspid valve replacement
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
Heart block after mitral surgery
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
Mitral valve exposure with potential injury to sinus node artery
Trans-septal approach through the right atrium
231
Prevention of and risk factors for AV groove dissociation
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
Most common cause of mitral stenosis
Rheumatic fever
233
Most common organism in prosthetic valve endocarditis
Coagulase-negative staphylococcus
234
Types of thoracoabdominal aneurysms
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
Indications for AICD in heart failure patients
Must meet these criteria:
- At least 40 days after MI
- EF 35% or less
- NYHA II or III symptoms
- Expected survival > 1 year
