Vascular/Cardio Flashcards

Question

mitral regurgitation

Answer 1

* Caused by abnormality of any component of the mitral valve apparatus * Most commonly caused by degenerative mitral valve dz (including prolapse) * Rheumatic heart disease still a common cause elsewhere in the world * Also infective endocarditis, trauma (including MI), congenital, or annular calcification * Surgical indications for repair/replacement: * Moderate to severe (grade \>3) MR in symptomatic patients or those with left ventricular (LV) dysfunction * Consider if severe LV dysfunction refractory to medical therapy with low likelihood of durable repair and low comorbidity * Asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk, and left atrial dilatation and sinus rhythm or pulmonary HTN on exercise

Answer 2

* Delaying surgery until moderate to severe symptoms occur is associated with increased perioperative and long-term mortality * MitraClip for severe MR in high-risk pts * TMVR is on the way...

Answer 3

* Almost always from rheumatic fever * Need aggressive rheumatic fever prevention/treatment * LV dilatation \>45mm associated with high incidence of atrial fibrillation * Often managed by Interventional Cardiology with percutaneous mitral balloon commissurotomy

Answer 4

* Risk of tamponade (emergency) * Typically pericardiocentesis preferred, but must have \>1 cm anterior effusion on echo * If not, then surgery indicated (for safety) * Small, organized, or loculated effusions (cannot tap) * Malignant, traumatic, or purulent pericardial effusions → pericardial window preferred for longer term tx * Typically surgical approach is subxiphoid pericardial window * Leave pericardial drain in place until drainage slows * Repeat echo or CT scan, monitor drainage

Answer 5

* Type A involves ascending aorta - a true emergency * Wall rupture * Hemopericardium or tamponade * Occlusion of coronary arteries with MI * Severe aortic insufficiency * Typically Type B can be managed medically (beta-blockers; keep BP low) and then evaluated by vascular surgery * Mediastinal widening present in 80% CXR * Typically following by CTA per protocol in a stable enough patient, otherwise TTE can work * Most commonly: * ~2.2 cm above the aortic root * Distal to the left subclavian artery * Aortic arch * Etiology: * HTN * Pregnancy * Cocaine * Chest trauma * Iatrogenic * Syphilitic aortitis * Arteriosclerosis * HLD * Smoking * Many congenital factors, including connective tissue disorders * High morbidity and mortality for acute dissection (\<2 weeks). 1-2% die per hour for the first 24-48 hours * Better prognosis if chronic dissection (\>2 weeks old; more stable)

Answer 6

* Not common, but good to recognize * “Spontaneous” (forceful coughing) vs * Blunt force * Penetrating chest trauma * Esophageal tear/rupture * Iatrogenic (esophageal or endobronchial procedures, chest surgery) * Lung disease * Mechanical ventilation * Not really well understood, thought that air from ruptured alveoli tracks along peribronchial vascular sheaths to the hilum of lungs, then into the mediastinum * Also connects with submandibular space, retropharyngeal space, and vascular sheaths in the neck * Free air can cause pneumopericardium, pneumothorax, subcutaneous emphysema pneumoperitoneum, or pneumoretroperitoneum * Treatment is usually observation * Esophageal injuries more commonly require intervention or close following * Chest tube indicated only if concurrent pneumothorax * Avoid strenuous physical activity until resolved * Avoidance of coughing/vomiting, addressing whatever led to the condition

Answer 7

* **_CXR_**: standard imaging study to evaluate chest pathology: pneumothorax, pleural effusion, lung tumors * **_CT scan of chest_**: very frequently used imaging modality to evaluate intrathoracic pathology * **_PET/CT scan_**: standard test for lung cancer evaluation * *CT-guided biopsy*

Answer 8

* Evaluation of paratracheal space for biopsy of lymph nodes: lung cancer, lymphoma, sarcoidosis * Outpatient procedure, general anesthesia * Risks: injury to great vessels, bronchus, recurrent laryngeal nerve, pleura, lung * In my practice, usually reserved for lung cancer staging via biopsy to guide treatment

Answer 9

* The treatment for lung cancer is stage-dependent (TNM linked below) * Preop evaluation: * imaging studies * PFT (FEV1/DLCO) and estimation of postoperative FEV1/DLCO * Cardiac evaluation * Management of co-morbidities * Stages I/II: lobectomy & mediastinal lymph node dissection/biopsy * Sublobar resection for high-risk limited lung reserve * Stage IIIA: potentially resectable disease: multimodality (induction chemo/SX/PORT or chemoXRT/surgery) * Unresectable stageIIIA/B: chemoXRT * Stage IV: chemotherapy

Answer 10

* 85% of all lung cancers * The most common signs and symptoms of lung cancer: * Cough * Chest pain * Shortness of breath * Hemoptysis * Wheezing * Dysphagia/Hoarseness * Recurring infections such as bronchitis and pneumonia * Weight loss and loss of appetite * Fatigue * Metastatic signs and symptoms: * Bone pain * Spinal cord impingement * Neurologic problems such as headache, weakness or numbness of limbs, dizziness, and seizures

Answer 11

* Open thoracotomy: muscle splitting of muscle sparing thoracotomy, division of intercostal muscle and spreading of ribs * Minimally invasive thoracoscopy (small incision, no rib spreading, anatomic lung resection) * Video-assisted thoracoscopy (VATS) * Robot-assisted thoracoscopy * Surgeon dependent

Answer 12

* **VATS lung resection: minimally invasive** * Small incisions, no rib spreading * Oncologically similar to open surgery * Less pain, reduced stress-response, reduced LOS, early return to work * **Robotic lung resection: minimally invasive** * Emerging technology with increasing numbers of adopters * Similar results as VATS lung resection * VATS as mentioned previously is a surgical approach * Also use VATS for other diseases and pathologies * Lung biopsies are fairly common, especially for interstitial lung disease, suspected TB * Open thoracotomy * In both approaches, ideally have one-lung ventilation by the anesthesiologist to deflate the operating side (usually using a double-lumen ET tube) * Lateral decubitus positioning helps by gravity perfusing the ventilating lung

Answer 13

* Many reasons for effusion, but figuring out the etiology guides treatment * Typically recommend ultrasound-guided thoracentesis (most often by Interventional Radiology) with pleural fluid analysis if it’s the first time * If there’s enough fluid to tap * Different recommendations if it’s chronic, would explore surgery or permanent chest tubes in some cases * Exudative vs. transudative? * Another common cause mentioned earlier is post-CABG left pleural effusion * Would this be exudative or transudative??

Answer 14

* Wide variety of presentations depending on etiology * _Spontaneous ptx:_ usually asymptomatic until a bleb ruptures, then SOB, dyspnea like in our case * Tall, thin males * Secondary SP: variety of lung diseases * _Iatrogenic or traumatic ptx_: similar presentation, different history * _Tension ptx:_ Hypotension, hypoxia, chest pain, dyspnea * _Catamenial ptx_: (rare) women 30-40yo, within 48h of menstruation, right-sided * Thought to be from endometriosis of the pleura * Always listen for breath sounds and compare sides, best way to tell (and then wait for your CXR) * Typically administer oxygen right away then assess depending on size, symptoms if chest tube is needed * If \<15-20% can observe with repeat CXRs in ED * Surgery indicated if recurrent (2+), would need CT scan to look for blebs, resection * Usually VATS with bleb resection and pleurodesis * Pleurodesis is the process of creating an inflammatory reaction between the chest wall and lung pleura to make it “stick” * Mechanical or with talc * Ongoing care: * No flying until completely resolved * No smoking

Answer 15

* Chest tubes are very common, placed after almost all lung surgeries * CT service manages a lot of chest tubes in the hospital (even if placed by ED or IR) * The chest tube is ALWAYS connected to some sort of chamber, collection device, or more commonly, a Pleur-evac * Chest tubes are NEVER connected directly to wall suction (I’ve seen this too many times in my short career) * Never disconnect a chest tube from a device without clamping it first or having other guidance as you can cause a pneumothorax * To test for a bronchopleural fistula (more casually called an air-leak), have patient valsalva (cough) and watch water seal chamber for bubbles * Persistent air leaks aren’t uncommon after surgery (injury to lung) * If a chest tube is on suction, it is connected to a canister, on CONTINUOUS suction (not intermittent), usually -20cm H2O * “Water seal” means off suction because there is a column of water that “seals” the end of the chest tube system (don’t want air getting back in, it’s a closed system * Daily chest x-rays are standard with a chest tube in place * Heimlich Valve can be placed for discharge if CT can’t be removed (ongoing air-leak) * Many different kinds and sizes of chest tubes * Usually sutured in place * Always make sure drainage unit is below insertion site (gravity) * Check for kinks, properly secured to patient * To remove a chest tube, must cut suture holding it in place * U-stitch vs no U-stitch...the jury is out * Removing a chest tube * Once drainage is minimal (effusion usually \<200cc/day) * Or once air leak resolves (and has been on water seal) * Controversial but some providers clamp chest tubes for 4 to 24 hours to prove there is no further air leak * Cut suture holding chest tube * Don’t cut the U-stitch if one is in place, since that is what you tie down after tube comes out * Have someone hold pressure while you quickly pull tube out * Then apply occlusive dressing (usually Xeroform) and gauze, leave in place 48-72 hours) * For larger bore surgical chest tubes, I usually give 2mg morphine IV prior to removal, but discuss with patient first * Ask them to hold breath while you swiftly remove