Cardiothoracic Surgery

procedure recommended for 50 year old with aortic stenosis

open heart surgery (NOT TAVR)- too young for TAVR

Indications for CABG

-Greater than 50% blockage in left main artery
-Other vessels > 70% or 50-70% proximal or mid lesion with a positive fractional flow reserve (less than 0.8)
-Two vessel disease involving LAD and RCA or Vx in patients with DM or a large area of myocardium supplied by diseased vessels
-Multivessel disease

Indications for surgery for aortic stenosis

Severe symptomatic
Symptomatic critical aortic stenosis
Aysmptomatic AS with decreased EF

Aortic stenosis diagnosed with....

echocardiogram

MC cause of mitral stenosis

rheumatic fever

Indications for mitral stenosis surgery

Severe symptomatic MS despite optimal medical therapy
Asymptomatic with severe pulmonary HTN
Asymptomatic with decreased LVEF
New onset of Afib (progressive dilation of LA)

Acute mitral regurgitation can occur _____ and can cause

after MI with rupture of papillary muscle or chordae teninae
Causes cardiogenic shock and acute pulmonary edema due to increased LA pressure (body didn't have time to compensste- chronic regurg has normal pressures)

Main cause of tricuspid regurgitation

Endocarditis (S. aureus)

Gold standard test for endocarditis

echocardiogram

Indications for surgery- endocarditis

s/s of heart failure
Persistent bacteremia with appropriate antibiotic therapy for 5-7 days
Fungal infection
Recurrent emboli
Large mobile vegetation > 10 mm
Valvular disease
Heart block

Meds to treat symptomatic ventricular septa defect

Lasix and digoxin

S/S of VSD

Can be asymptomatic
Bluish color lips, nails, skin
Failure to thrive, trouble feeding
SOB
Fatigue
LE edema

Type A aortic dissection tx

Open heart surgery

De Bakey Type 1

originates in the ascending aorta ,elongates to the arch and possibly the descending

De Bakey type II

Originates in and is confined to the ascending aorta

De Bakey type III

Originates in the descending aorta and extends distally down the aorta or, rarely, retrograde into the aortic arch and ascending aorta

Stanford type A aortic dissection

All dissections involving ascending aorta, regardless of the site of origin

Stanford Type B aortic dissection

All dissections NOT involving ascending aorta

Type B uncomplicated aortic dissection tx

Medical therapy

Sternal precautions required for ____ post op

6-8

Indications for carotid endarterectomy (CEA)

•Symptomatic patients with TIA or minor CVA with 70-99% stenosis and no ipsilateral endarterectomy
•Symptomatic patients with 50-69% stenosis
•Asymptomatic patients with 60% or greater stenosis

Contraindications for carotid endarterectomy (CEA)

•Asymptomatic complete carotid occlusion- absolute contraindication
•Acute major CVA
•PMH that increases perioperative risk (CAS in these patients)
•Major CVA with minimal recovery
•Significantly altered level of consciousness

Gold standard in diagnosing carotid artery stenosis

Angiogram

S/S of peripheral artery disease

•Initially asymptomatic
•Claudication- LE pain with activity and relieved with rest
•LE pain at rest
•Ulcers
•Skin changes
•The 5 P's (Pulselessness, Paralysis, Paraesthesia, Pain & Pallor)

Rutherford's classification of PAD

Treatment of

Conservative management

Treatment of > 5.5 cm and asymptomatic AAA

Elective repair

Symptomatic AAA treatment

Elective repair

second most common cancer

lung cancer

Typical lung cancer is ____ grade
Atypical is ____

low grade
intermediate grade

T/F: lung cancer metastasis is rare and has an excellent prognosis

True

SPHERE pneumonic - complications of lung cancer

Superior vena cava syndrome
Pancoast tumor
Horner syndrome
Effusion
Recurrent laryngeal symptoms
Endocrine

TNM staging

classifies cancer according to tumor size, node involvement, metastasis

Pneumonectomy

•A surgical procedure in which an entire lung is removed. A pneumonectomy is most often done for cancer of the lung that cannot be treated by removal of a smaller portion of the lung. A pneumonectomy is an open chest technique (thoracotomy).

Lobectomy

Also called a pulmonary lobectomy, it is a common surgical procedure that removes one lobe of the lung that contains cancerous cells. Removal of two lobes is called bilobectomy.

Sleeve lobectomy

•A surgical procedure that removes a cancerous lobe of the lung along with part of the bronchus (air passage) that attaches to it. The remaining lobe(s) is then reconnected to the remaining segment of the bronchus. This procedure preserves part of a lung, and is an alternative to removing the lung as a whole (pneumonectomy).

Wedge resection

A wedge resection is a surgical procedure during which the surgeon removes a small, wedge-shaped portion of the lung containing the cancerous cells along with healthy tissue that surrounds the area. The surgery is performed to remove a small tumor or to diagnose lung cancer. A wedge resection is performed instead of a lobectomy (removing a complete lung lobe) when there is a danger of decreased lung function if too much of the lung is removed. A wedge resection can be performed by minimally-invasive video-assisted thoracoscopic surgery (VATS) or a thoracotomy (open chest surgery).

Segment resection

•A segment resection removes a larger portion of the lung lobe than a wedge resection, but does not remove the whole lobe.

Porcelain aorta

Porcelain aorta: extensive calcification of the ascending aorta or aortic arch, can cause issues with aortic cross-clamping or aortotomy

Dental clearance may be needed for CT surgery to avoid...

infective endocarditis

DOC for malignant hyperthermia that may be caused by use of halogenated anesthetics

IV Dantrolene

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. Release of Calcium
High fever, muscle rigidity

ECMO

What arrhythmia is MC after CT surgery

a fib

Common vessels used for CABG

internal mammary artery
saphenous v
radial a

Severe aortic stenosis grading: Valve area and aortic velocity

Area:

Lung mass vs nodule

Nodule:

Fleishner Society grading of lung nodules

MC type of lung cancer

Adenocarcinoma (non-small cell)

Stage 1 lung cancer

Tumors only in lung - NOT in lymph nodes yet

Stage 2 lung cancer

In lungs and near the lymph nodes

Stage 3 lung cancer

In lungs and spread to lymph nodes

Stage 4 lung cancer

Spread to lungs, around the lungs and other organs (distant metastasis)

pain in hands and legs is indicative of what type of lung CA?

Adenocarcinoma (NSC)

Horner's syndrome symptoms

ptosis, myosis, anhydrosis

Paraneoplastic syndrome treatment

Supportive/ symptomatic care
Immunotherapy

paraneoplastic syndrome

medical condition caused by tumor secretions (hormones, cytokines, TNF, Interleukin-1), may cause hypercalcermia, hypoglycemia, SIADH

SVC syndrome s/s

JVD
UE edema
Facial edema
Dyspnea
HA
Dizzy

Pancoast tumor

Occurs in apex of lung and causes horner syndrome
Shoulder and ulnar hand pain

Absolute contraindication to carotid endarterectomy (CEA)

Asymptomatic complete carotid occlusion

ABI - normal, mild to moderate and severe disease

0.91-1.30 --> normal
0.41-0.90 --> mild to moderate PAD
0.00-0.30 --> severe PAD

how to calculate ABI

Right side: Higher right ankle pressure / higher arm pressure

Paraneoplastic syndromes

symptom complexes arising in patients with cancer that cannot be explained by local or distant spread of their tumors