Surg Med - Exam 2 - CV Surgery

CAD - Surgical Indications

Multivessel CAD (MV CAD), especially involving the proximal LAD, and in patients with DM

Left main coronary artery (LM) disease

Multivessel CAD with reduced EF/LV dysfunction 

Persistent angina/symptomatic ischemia despite medical therapy, esp in MV disease

CAD anatomy not amenable to PCI/stenting or failed PCI

CABG

what is the primary surgery for CAD?

Coronary Artery Bypass Graft

Surgical revascularization using grafts (saphenous vein or internal mammary artery) to bypass stenosed coronary arteries

CABG Indications

Multivessel CAD with proximal LAD dz especially in DM

Left main CAD (bc big area of distribution - lots of heart m at risk)

Multivessel CAD with depressed EF

Relief of angina in the setting of multivessel dz

CABG - CI

No absolute CIs

Relative CIs → asx pts w/ low risk of MI/death, comorbidities,

advanced age

CABG Comp

Stroke, MI, infection, bleeding, graft occlusion, atrial fibrillation, renal dysfunction

Percutaneous Coronary Intervention

Balloon catheter dilates atherosclerotic coronary artery; often followed by stent placement

PCI Indications

Acute and chronic occlusion of coronary arteries

MI; occlusion of bypass grafts and stents; recurrent ischemia after PCI or bypass surgery

PCI CI

Absolute → pt refusal

Relative → comorbidities (decompensated HF, acute renal failure, uncontrolled and severe HTN, bleeding d/o or anticoagulated state, allergy to radiographic agents)

PCI Comp

Vessel dissection, restenosis, MI, stent thrombosis, bleeding at access site

Cardiopulmonary Bypass Components

Cannulas (venous and arterial)

Reservoir

Suction and Vent Catheters

Heater/Cooler (AKA radiator)

Oxygenator

Pump (roller vs centrifugal)

Arterial Filter

Cardioplegia Pump

CPB Description

Machine temporarily takes over heart/lung function during surgery → provides a bloodless and stable surgical field

CPB Indication

Needed for most open-heart surgeries (valve replacement, CABG)

CPB CI

Relative; severe atherosclerosis, poor cardiac reserve

CPB Comp

Coagulopathy, hemolysis, air embolism, neurocognitive deficits ("pump head")

Post-Pericardiotomy Syndrome

A syndrome consisting of new pericardial and/or pleural effusions, pericardial rub on exam and chest pain sometimes associated with dyspnea, fever, and elevated inflammatory markers

1-6 weeks post op

when does post-pericardiotomy syndrome usually occur?

Post-Pericardiotomy Syndrome Dx

CXR

TTE

Elevated CRP in absence of infection

Post-Pericardiotomy Syndrome Tx

Corticosteroids

NSAIDs

Colchicine for refractory

Surgical Aortic Valve Replacement (SAVR)

Open heart surgical replacement of the aortic valve with a mechanical or bioprosthetic (tissue) valve

Severe symptomatic aortic stenosis

Severe aortic regurg with sx, LV dysfunction, or LV dilation

Younger/low surgical-risk pts often preferred for SAVR

SAVR Indications

Severe symptomatic aortic stenosis

Severe aortic regurg with sx, LV dysfunction, or LV dilation

Younger/low surgical-risk pts often preferred for SAVR

SAVR CI

Prohibitive surgical risk/frailty

Severe comorbidities limiting survival benefit

SAVR Comp

Bleeding, infection, stroke, MI

Prosthetic valve thrombosis/endocarditis

Conduction abnormalities requiring pacemaker

Mechanical valves requiring lifelong warfarin anticoagulation

Transcatheter Aortic Valve Replacement (TAVR)

Catheter-based placement of a bioprosthetic valve within a stent, usually via the femoral artery

TAVR Indications

Severe symptomatic aortic stenosis

Pts at high, intermediate, or selected low surgical risk

Older pts or those w/ significant comorbidities

TAVR CI

Inability to obtain vascular access

Active endocarditis

Unsuitable valve/root anatomy

TAVR Comp

Vascular access injury

Stroke

Paravalvular leak

Conduction abnormalities/need for permanent pacemaker

Valve malposition or coronary obstruction

Mitral Valve Repair and Replacement (MVR)

Surgical correction of mitral valve disease by repairing the native valve or replacing it with a prosthetic valve; repair is generally preferred when feasible

MVR Indications

Severe symptomatic mitral regurgitation

Acute MR (e.g. papillary muscle rupture)

Severe mitral stenosis requiring intervention

Asymptomatic severe MR with LV dysfunction/dilation

MVR CI

Extreme surgical risk

Severe comorbidities limiting benefit

MVR Comp

Bleeding, infection, stroke

residual/recurrent MR

Prosthetic valve thrombosis or degeneration

Need for anticoag with mechanical valves

Arrhythmias (esp Afib)

Transcatheter Mitral Valve Repair (TEER)

Currently approved for prohibitive surgical risk patients (STS mortality risk >8%)

catheter-based

TEER Indications

Severe symptomatic MR in pts with prohibitive or very high surgical risk

Currently approved for pts with elevated operative risk (STS mortality risk > 8%)

TEER CI

Unsuitable mitral valve anatomy

Severe mitral stenosis

Active endocarditis

TEER Comp

Residual MR

Device detachment/malposition

Mitral stenosis from overcorrection

Vascular access complications

Stroke

Triscupid Valve Repair/Replacement

Surgical repair (usually annuloplasty) or replacement of the tricuspid valve

Indications

Tricuspid Valve Repair Indications

Severe symptomatic tricuspid regurgitation

Right sided HF sx (ascites, edema, hepatic congestion)

Severe TR undergoing left sided valve surgery

Tricuspid Valve Repair CI

Severe irreversible RV failure

Prohibitive operative risk

Tricuspid Valve Repair Comp

Bleeding, infection

Heart block/conduction disturbances

Residual or recurrent TR Prosthetic valve dysfunction

RV failure

Mechanical Valves

Made from durable synthetic materials (carbon, titanium)

Mechanical Valve Advantages

Extremely durable

Often last > 20-30 yrs

Good for younger patients

Mechanical Valves Disadvantages

High risk of thrombus formation

Require lifelong anticoagulation (usually warfarin)

Increased bleeding risk

Audible valve click may bother some patients

Mechanical Valves Pt Selection

Younger patients (< 50-60 yrs)

Patients already requiring anticoagulation

Patients able to comply with INR monitoring

Bioprosthetic Valves

Made from porcine, bovine, or human tissue

Bioprosthetic Valves Advantages

Lower thrombosis risk

Usually do not require lifelong anticoagulation

Lower bleeding risk

Quieter valve function

Bioprosthetic Valves Disadvantages

Less durable

Structural degeneration over time

May require replacement after 10-20 yrs

Bioprosthetic Valves Pt Selection

Older pts (> 65 yrs)

Patients with contraindications to anticoagulation

Patients unable to maintain regular INR monitoring

Patients desiring pregnancy

Ventricular Septal Defect Surgical Indication

Large defect

HF sx

Qp:Qs > 2

Pulmonary HTN

Failure to thrive

VSD Procedure

Surgical patch closure or transcatheter device closure

PDA Surgical Indications

Persistent PDA causing significant L → R shunt

HF sx

Pulmonary HTN

PDA Procedure

Percutaneous device closure or surgical ligation/division

TOF Surgical Indications

Significant pressure gradient

HTN

HF sx

TOF Procedure

Resection with end-to-end anastomosis

Patch aortoplasty or stent replacement

Transposition of Great Vessels Surgical Indications

Requires early definitive repair after stabilization

Procedure: Arterial switch (Jatane procedure) following PGE1 , +/- balloon atrial septostomy

Cardiac Tumors Surgical Indications

Symptomatic tumors

Embolic risk

Obstruction

Suspected malignancy

Thoracic Aortic Aneurysm Surg Indications

Generally ≥ 5.5 cm (lower threshold for BAV/connective tissue d/o)

Rapid growth/sx

Aortic Dissection Surg Indications

Type A (ascending) dissections are surgical emergencies

Complicated type B dissections may require intervention

Aortic Dissection Procedure

Resection of dissected aorta with graft replacement +/- root/arch repair