Valvular+ IHD- Therapy Flashcards
What are the causes of cardiac ischaemia?
- Atherosclerosis
- Embolism
- Coronary thrombosis
- Aortic dissection
- Arteritides
- Congenital
What is arteritides?
Inflammation of the arteries
How can IHD manifest itself?
- Angina
- MI
- Arrhythmias
- Chronic Heart Failure
- Sudden death
What are the 2 major dangerous patterns of coronary artery disease?
- Left main stem stenosis
- 3 vessel coronary artery disease
What are the indications for CABG?
- Symptomatic (any CAD pattern)
- Prognostic (LMSS, 3VDx)
What is the criteria for selection of patients for CABG?
- Adequate lung function
- Adequate mental function
- Adequate hepatic function
- Ascending aorta OK
- Distal coronary targets OK
- LV EF>20%
What are the conduits for CABG?
- Reversed saphenous vein
- Internal mammary arteries
- Radial arteries
What problems may arise related to sternotomy?
- Wire infection
- Painful wires
- Sternal dehiscence
- Sternal malunion
What post-op problems are there in cardiac surgery?
- Cardiac tamponade
- Stroke
- Death
What are the primary features of cardiac tamponade following cardiac surgery?
- Raised CVP
- Raised HR
- Low BP
What are the secondary features of cardiac tamponade following cardiac surgery?
- Oliguria
- Increased oxygen requirements
- Metabolic acidosis
What is the treatment for cardiac tamponade after cardiac surgery?
Chest re-opening
What are the long term outcomes post CABG?
- 50% have no further cardiac problems 10 years later
- Of the 50% who do have a problem, the majority are minor and easily controlled with medication
- 5% of patients may require repeat CABG
What are the main surgeries carried out on adults fro valvular heart disease?
Aortic and mitral valve surgery
What are the main paediatric surgeries carried out for valvular heart disease?
All 4 heart valves operated with roughly equal frequency
What causes of valvular heart disease in adults are there?
- Degenerative
- Congenital
- Infective
- Inflammatory
- LV or RV dilatation
- Trauma
- Neoplastic
- Paraneoplastic
What are the 3 most common valve problems requiring cardiac surgery in Aberdeen?
- Senile tricuspid AS
- Bicuspid AS
- Degenerative MR
What is rheumatic fever?
A relapsing illness related to streptococcal infections
What is the hallmark pathology of rheumatic fever?
Pancarditis
What other manifestations are usual with rheumatic fever?
- Skin
- Joint
- Sydenham’s chorea/ St Vitus’ Dance
How is rheumatic fever treated?
Aspirin and bed rest
What investigation is used in the diagnosis of rheumatic fever?
ASO titre
What odes chronic rheumatic heart disease lead to?
Gradually progressive mitral valve disease with/without aortic valve disease
What is the most common organism responsible for endocarditis?
Strep viridans
What is the second most common organism responsible for endocarditis?
Staph aureus
What type of endocarditis does strep viridans give rise to?
Sub-acute bacterial endocarditis
What type of endocarditis does staph aureus give rise to?
Acute bacterial endocarditis
What is the prognosis for natural valve endocarditis?
90% chance of cure with antibiotics alone
What is the prognosis for prosthetic valve endocarditis?
50% chance of cure with antibiotics alone
How does the chances of cure for endocarditis vary dependent on the organism it is caused by?
Chances of cure are much higher with strep viridans than with staph aureus
What are the indication for surgery for endocarditis?
- Severe valvular regurgitation
- Large vegetations
- Persistent pyrexia
- Progressive renal failure
How long are antibiotic given for endocarditis post-operatively?
IV for 6 weeks
How does aortic stenosis typically present?
Typically presents as:
- Heart failure
- Syncopal episodes
- Angina
- Asymptomatic incidental finding
What is usually easily heard with aortic stenosis?
Murmur
How is aortic stenosis differentiated from aortic sclerosis?
Loss of aortic S2
How is LVH indicated on an ECG/ECHO?
AV gradient > 50mmHg
What is recommended for severe AS?
AVR
How does aortic regurgitation typically present?
- Heart failure
- Angina
- Asymptomatic incidental finding
What does the murmur tell us about AR?
- Usually difficult to hear
- The louder the murmur the more severe the AR
What is recommended for severe AR?
AVR especially when there is LV dilatation
What happens in severe AR during aortography?
The entire LV is filled with contrast after one diastolic interval
What does the murmur tell us about mitral stenosis?
- Murmur is usually difficult to hear
- If easily heard then the stenosis is severe
- May have toe exercise the patient to hear the murmur
Other than murmur, what may be present on auscultation of mitral stenosis?
Presystolic accentuation
When is surgery recommended for mitral stenosis?
If MVA on ECHO is <1.5cm2
What does the murmur tell us about mitral regurgitation?
- Murmur is usually easy to hear
- If murmur is loud, MR is usually severe
What is severe MR associated with?
LV and LA dilatation, onset of AF and pulmonary hypertension
What is recommended on the basis of severe MR being present?
MVR
What is severe MR on ECHO characterised by?
Systolic blood flow reversal in the pulmonary veins
How is cardiopulmonary bypass performed?
Blood drained from the RA and returned to the ascending aorta
What is necessary with cardiopulmonary bypass?
Systemic anticoagulation
What is induced during cardiopulmonary bypass?
Hypothermia
What kind of flow is there during CPB?
Non-pulsatile flow
What is the maximum time limit for CPB?
12 hours
What is the maximum cardiac ischaemic time?
6 hours
Who operates the CPB machine?
Perfusionists
What is a common problem in CPB?
Coagulopathy
What is more common in open cardiac procedures than in closed cardiac surgeries?
Air embolism
What are the 2 kinds of heart valve?
- Biological
- Mechanical
What is the advantage of the biological valve?
No warfarin required
What is the disadvantage of the biological valve?
It wears out after 15 years
What is the advantage of the mechanical valve?
Valve last >40 years
What is the disadvantage of the mechanical valve?
Warfarin required for life
When is mitral valve repair possible?
In many cases of degenerative MR
