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Cardio > Valvular & ischaemic heart disease therapy/surgery > Flashcards

Valvular & ischaemic heart disease therapy/surgery Flashcards

1
Q

Summarise the causes of cardiac ischaemia

A

Atherosclerosis
Embolism
Coronary thrombosis
Aortic dissection

Arteritides
Congenital

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2
Q

What does ‘arteritides’ mean?

A

Arteritis (type of vasculitis) is inflammation of the arterial walls caused by infection or autoimmunity

Can cause thrombosis which will cause Cardiac ischaemia if in coronary arteries

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3
Q

Summarise the clinical manifestations of Ischaemic heart disease

A 
Angina
MI
Arrythmias
Chronic heart failure
Sudden death
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4
Q

Coronary artery disease (IHD) can be classed by what coronary arteries are affected

Give 2 examples of types of coronary artery disease

A

Left main stem stenosis - (left coronary artery stenosis)

3 vessel coronary artery disease

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5
Q

In 3 vessel CAD, what coronary arteries are affected?

A

left anterior descending

Circumflex

Right coronary artery

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6
Q

What is CABG?

A

Coronary artery bypass graft

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7
Q

What are the criteria for selecting patient’s for CABG?

A

Lung function
Hepatic function
Mental function
Heart function - LV ejection fraction > 20%

Ascending aorta
Distal coronary targets

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8
Q

One of the criteria for CABG patients is ‘DIstal coronary targets must be okay’

What is meant by this?

A

Must be suitable vessel for the bypass to be connected to

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9
Q

In CABG surgery, what is a Conduit?

A

Vessel to be used for the bypass

This can be synthetic, but is usually just a vessel from elsewhere in the body

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10
Q

What vessels in the body are used for Conduits?

A

Reversed saphenous vein - from leg

Internal mammary arteries - aka Internal thoracic arteries from chest

Radial arteries - arm

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11
Q

What is a ‘Median Sternotomy’?

A

Surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or “cracked”

Allows access to heart for CABG

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12
Q

What complications are associated with a sternotomy?

A

Wire infection

Painful wires

Sternal dehiscence:

  • process of separation of the bony sternum
  • often is accompanied by mediastinitis (infection of the deep soft tissues)

Sternal malunion:
- Sternum doesn’t join back together properly

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13
Q

What are the main risks to patients post cardiac surgery

A

Stroke

Death

Cardiac tamponade:
- accumulation of fluid in the pericardial space

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14
Q

How is cardiac tamponade bad for heart function?

A

Fluid accumulation results in reduced ventricular filling and subsequent hemodynamic compromise

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15
Q

How would you identify a patient with cardiac tamponade?

A

Raised CVP,
Raised HR
Low BP

Oliguria (don’t pass urine)
Increased oxygen requirements
Metabolic acidosis

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16
Q

How is cardiac tamponade fixed?

A

Chest reopening

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17
Q

What are the long term outcomes for CABG patients?

A

50% have no further cardiac problems in 10 years

Of the 50% that do:

  • Most problems are minor and treated with medication
  • 5% of patients may require a repeat CABG
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18
Q

Contrast valvular heart disease surgery in adults & children

A

Adults - Mainly aortic & mitral valve surgery

Children - All 4 valves operated on at pretty much the same frequency

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19
Q

What are the causes of valvular heart disease in adults?

A 
Degenerative
Congenital
Infective
Inflammatory 
LV or RV dilatation
Trauma
Neoplastic 
Paraneoplastic
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20
Q

What are the most common valves that are diseased/require surgery?

(in aberdeen)

A

Senile tricuspid AS

Bicuspid AS

Degenerative MR

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21
Q

The Antistreptolysin O (ASO) titre test is used to test for what?

A

Rheumatic fever

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22
Q

Why is Rheumatic fever linked to CVS disease?

A

RF causes pancarditis

Chronic rheumatic heart disease:
- Gradually progressive MVDx +/- AVDx

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23
Q

What tends to cause rheumatic fever?

A

Streptococcal infections

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24
Q

Rheumatic fever can cause a disorder characterised by uncontrollable twitching/jerking of parts of the body

What disorder is this?

A

Sydenham’s chorea/ St Vitus’ Dance

streptococcal infections

25
Q

Why is chronic rheumatic heart disease clinically important?

A

Worldwide most common heart problem

Major cause of death in pregnancy

Can cause cardiac surgery to be undertaken during pregnancy

26
Q

What is Endocarditis?

A

Infection of endocardium

27
Q

What causes endocarditis?

A

Bacterial infection:

Strep viridans

  • Most common
  • SUB-ACUTE bacterial endocarditis

Staph aureus
- ACUTE bacterial endocarditis

28
Q

Why does endocarditis have clinical manifestations involving heart valves?

A

Endocardium makes up the valves

Therefore - damage to endocardium = damage to valves

29
Q

How is endocarditis treated?

A

Antibiotics - if bacterial

30
Q

The outcomes of antibiotic treatment of Valve endocarditis vary depending on the valves that are infected

Describe the differences in outcomes

A

‘Native’ valve endocarditis (NVE):
- 90% success from just Abx

Prosthetic valve endocarditis (PVE)”
- 50% success from just Abx

31
Q

Another factor that determines how effective antibiotic treatment for Valvular endocarditis is, is what bacteria caused the infection

Explain this

A

Bacterial infection of either Strep viridans or Staph aureus

Strep viridans is easier to treat so success is higher than that of Staph aureus

32
Q

If antibiotics do not cure valvular endocarditis, what happens?

A

Surgery (if suitable)

33
Q

What are the indications for surgery for endocarditis?

A

Severe valvular regurgitation

Large vegetations

Persistent pyrexia

Progressive renal failure

34
Q

How are patients managed after they have received surgery for endocarditis?

A

IV antibiotics for 6 weeks post surgery

35
Q

How does aortic stenosis present?

A

Usually through secondary effects:

  • Heart failure
  • Angina
  • Syncope / presyncope

Incidental finding

36
Q

How can aortic stenosis be identified on examination?

A

Auscultation:

  • Systolic murmur
  • Loss of aortic S2 sound (separates it from aortic sclerosis)
37
Q

How can aortic stenosis be identified on an ECHO?

A

Left ventricular hypertrophy

38
Q

Why can’t LVH be identified on palpation?

A

Right ventricular hypertrophy causes a palpable HEAVE

But LVH does not (usually) cause a heave

39
Q

Why is an ECG useful for identifying Aortic stenosis?

A

AV gradient > 50mmHg = Aortic stenosis

40
Q

What is the treatment for severe Aortic stenosis?

A

Replacement of Aortic valve

AVR

41
Q

Aortic regurgitation & aortic stenosis can present with similar signs

What are the signs of Aortic regurgitation, and how can the symptoms be used to differentiate between the two?

A

Heart failure
Angina

Aortic stenosis also causes syncope episodes so if patient had fainted or whatever, then that would indicate aortic STENOSIS and not regurgitation

42
Q

How could you differentiate between Aortic regurgitation & aortic stenosis on examination?

A

Aortic stenosis = systolic murmur

Aortic regurgitation = diastolic murmur (hard to hear)

43
Q

If severe aortic regurgitation persists for a long time, what effect can it have on the heart?

A

LV dilation

44
Q

How would aortography be used to diagnose severe aortic regurgitation?

A

Imaging would show the entire LV is filled with contrast after one diastolic interval

45
Q

How does mitral valve stenosis sound on auscultation?

A

Murmur is usually difficult to hear
(May have to exercise the patient to hear the murmur)

If easily heard then the stenosis is severe

Presystolic accentuation may be present

46
Q

Because auscultation for mitral valve stenosis is fairly difficult, what other investigative technique is important?

A

ECHO

47
Q

ECHO investigation can identify severe mitral stenosis & indicate the need for surgery

How would an ECHO indicate that MVS is severe enough?

A

Surgery recommended if MVA on ECHO is < 1.5cm2

48
Q

Which is easier to hear, Mitral stenosis or regurgitation?

A

Mitral regurgitation easily heard

49
Q

What are the effects of severe mitral regurgitation on the Cardiovascular system?

A

Severe MR is associated with LV and LA dilatation, onset of AF and pulmonary hypertension

50
Q

How would an ECHO indicate severe Mitral regurgitation?

A

Severe MR on ECHO characterised by systolic blood flow reversal in the pulmonary veins

Severe MR = MVR surgery needed

51
Q

Heart valve replacement surgery requires surgeons to be cutting up someones heart - meaning its not working (obviously)

What bit of machinery is thus needed for this surgery?

A

Cardiopulmonary bypass machine

Operated by perfusionists

52
Q

How is the flow of blood different using a CPB machine?

A

Non-pulsatile flow

53
Q

What type of drugs are needed when using CPB?

A

Systemic anti-coagulants

This creates the risk of coagulopathy

54
Q

What happens to a patients body temperature when using a CPB machine?

A

Induced hypothermia

No clue why

55
Q

What is the time limit on cardiac surgery using a CPB machine?

A

12 hours max

Maximum cardiac ischaemic time is 6 hours

56
Q

What is a specific risk associated with open surgery, such as valve replacement surgery?

A

Air embolism

57
Q

What are the 2 types of replacement valves, and the advantages/disadvantages of each

A

Biological valve:
- No warfarin needed, however, it wears out after 15 years

Mechanical valve:
- Warfarin needed, but it lasts much longer > 40 years

58
Q

Is Valve replacement the only surgical option for treating all these valve problems?

A

Mitral valve repair is often possible for degenerative Mitral regurgitation

This is preferred to replacement if full competence can be restored

Cardio (41 decks)

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