valvular and ischaemic heart disease - therapy

Question 1

Causes of cardiac ischaemia (6)

Answer 1

Atherosclerosis
Embolism
Coronary thrombosis
Aortic dissection
Arteritides - arteries themselves become inflamed
Congenital

Question 2

Patient with ischaemic heart disease may present with what? (5)

Answer 2

angina
MI
arrythmias
chronic heart failure
sudden death 

frequently symptoms aren’t present - esp in patients with diabetes

Question 3

what is 3 vessel coronary artery disease

Answer 3

left anterior descending, right coronary and circumflex arteries have blockages from atherosclerotic plaques

Question 4

left main stem stenosis

Answer 4

narrowing of left main coronary artery

Question 5

what is the recommended treatment for both left main stem stenosis and 3 vessel coronary artery disease

Answer 5

coronary artery bypass grafting

Question 6

selection of patients for coronary artery bypass grafting

Answer 6

Adequate lung function

Adequate mental function - no dementia

Adequate hepatic function

Ascending aorta OK

Distal coronary targets OK
LV Ejection Fraction (% of blood in LV that is being pushed out/) > 20%

Question 7

which arteries/veins are used as grafts for bypass surgery

Answer 7

Reversed saphenous vein (in the leg)
Internal mammary arteries (run down either side of the sternum)
Radial arteries (in the arms)

Question 8

when using the radial artery what must there be in the ulnar artery

Answer 8

good collateral flow - good at diverting blood to alternate route around a blocked vessel etc

Question 9

what is used to stop the heart in systole during CABG surgery and why?

Answer 9

cardioplegia solution

protects the myocardium during open heart surgery

Question 10

define sternotomy

Answer 10

type of surgical procedure in which a vertical inline incision is made along the sternum

Question 11

sternotomy related problems?

Answer 11

Wire infection
Painful wires
Sternal dehiscence (wound ruptures along a surgical incision)
Sternal malunion (not healing well)

Question 12

what is Cardiac Tamponade and what are signs of it?

Answer 12

fluid in the pericardial space

primary features - rasied CVP, raised heart rate, low BP

secondary features - oliguria (low urine output), increased O2 requirements, metabolic acidosis

Question 13

how is cardiac tamponade treated?

Answer 13

chest reopening

Question 14

long term outcomes of CABG

Answer 14

50% have no problems 10 years later
50% who do have problems - only minor

5% may need another CABG

Question 15

Difference between adult and paediatric cardiac surgery?

Answer 15

Adult Cardiac Surgery – Mainly aortic and mitral valve surgery

Paediatric Cardiac Surgery – All four heart valves operated with roughly equal frequency - pulmonary and tricuspid valves only usually operated on in children

Question 16

Cause of valvular heart disease in adult (8)

Answer 16

Degenerative
Congenital
Infective - endocardosis - destruction of valves
Inflammatory 
LV or RV dilatation
Trauma
Neoplastic 
Paraneoplastic

Question 17

what organism commonly cause subacute and acute bacterial endocarditis?

Answer 17

subacute - strep viridans

acute - staph aureus

Question 18

out of acute and subacute bacterial endocarditis which one needs treated faster

Answer 18

acute

Question 19

what % chance is there of treating natural or prosthetic valve endocarditis?

Answer 19

Natural - 90%

prosthetic- 50%

Question 20

indications for surgery in endocarditis

Answer 20

Severe valvular regurgitation
Large vegetations
Persistent pyrexia - fever
Progressive renal failure

Question 21

severe heart failure cannot be treated with what?

Answer 21

medication, patient must be operated on

Question 22

what treatment is given after surgery for endocarditis?

Answer 22

IV antibiotics for 6 weeks

Question 23

recommended treatment for aortic stenosis

Answer 23

aortic valve replacement

Question 24

treatment of mitral stenosis

Answer 24

surgery recommended if mitral valve is larger than 1.5cm squared

Question 25

cardiopulmonary bypass surgery process

Answer 25

Blood drained from the Right Atrium and returned to the ascending aorta (doesn’t go to lungs)

the heart and lung function is taken over by CPB machine

induced hypothermia
systemic anticoagulation - heparin

Question 26

what is more common in open heart surgery like valve replacement than closed heart operations such as CABG?

Answer 26

air embolism

Question 27

What options are available for prosthetic

heart valves?

Answer 27

biological valve
mechanical valve
mitral valve repair

Question 28

biological valve

Answer 28

no warfarin required but the valve wears out after 15 years

ie pig hearts for elderly - fall apart after a few years but no warfarin needed

Question 29

mechanical valve

Answer 29

Warfarin required for life. Valve lasts for > 40 years

Question 30

Mitral valve repair

Answer 30

possible in many cases of degenerative MR. When complete valve competence is restored, repair is better than replacement for the mitral valve.