1
Q
Cyanotic congenital heart defects
A
-All start with “T”
2
Q
Atrial Septal Defect
A
- Any defect in the atrial septum that allows flow
- Fetal physio: patency of foramen ovale allows R-L flow to bypass lungs.
- In adults, L pressure is greater than R pressure allowing flow to go from left to right. R pressures will start to rise and reverse the shunt, causing deoxygenated blood to flow to the body
- Sx: Fixed S2 split, midsystolic ejection murmur, enlarged RA and RV on CXR
- Tx: surgical closure
3
Q
Coarctation of the Aorta
A
- Narrowing of the aorta distal to take off of the left subclavian artery
- RFs: turner’s syndrome, males
- Workup: CXR (aortic knob, coarctation, dilated poststenotic aorta), echo, cardia cath
- Dx: disparity of BP between upper and lower extremities
- Sx: diminished femoral pulses, severe HTN, HA, epistaxis, claudication, continuous systolic murmur
- Tx: Surgery=resection with end to end anstomosis, subclavian artery flap, patch graft, interposition graft, percutaneous repair option
- Post op complications: parplegia, HTN, horner’s syndrome, injury to recurrent laryngeal nerve
4
Q
Ventricular Septal Defect
A
- Most common congenital heart defect
- High rate of spontaneous closure (if small)
- L to R shunt–> increased pulmonary blood flow
- Sx: LVH on EKG, enlarged LV on CXR
- Tx: intracardiac closure is TOC, transcatheter can also be used
5
Q
Patent Ductus Arteriosus
A
- Physiologic R to L shunt in fetal circulation connected the pulmonary artery to the aorta bypassing the lungs-Normally closes shortly after birth
- Prostaglandins maintain patency
- Will become L to R shunt after birth
- Sx: continuous “machinery” murmur, poor feeding, respiratory distress, CHF
- Dx: PE, echo, catheter
- Tx: indomethacin or other NSAIDs(inhibit prostaglandins), surgical ligation, percutaneous closure
6
Q
Tetralogy of Fallot
A
- Most common cyanotic congenital heart disorder
- Etiology: Misalignment of the infundibular septum in early development
- Tetrad:
- Pulmonary stenosis/obstruction of the R ventricular outflow
- Overriding aorta
- RVH
- Large VSD
- Sx: hypoxic spells, cyanosis, clubbing, murmur
- Dx: CXR, echo
- Tx: Intracardiac repair with closure of VSD and relief of pulmonic stenosis. May need re-op. In non-surgical candidates: subclavian artery to pulmonary artery shunt to get blood flow to the lungs.
7
Q
Pacemaker/AICD
A
- Pacemaker: Maintain HR when natural pacemaker is not fast enough or there is a block in the heart’s electrical conduction system
- AICD(automatic implantable cardioverter defibrillator): small battery powered electrical impulse generator implanted in pts who are at risk of SCD due to V fib and Vtach. It detects cardiac arrhythmia and corrects it by delivering jolt of electricity
- Procedure: anesthesia and possible IV abx. Large needle in a vein usually near the shoulder opposite dominant hand. Thread needle through vin to the correct place in the heart. X ray is used to guide. Incision is made in the chest or abdomen. Metal box goes in incision under the skin and connects to the wires.
8
Q
Coronary Artery Disease
A
- Atherosclerotic occlusive lesions of the coronary arteries
- Number 1 killer of men and women in the US
- 3 vessels most often affected: LAD, circumflex, and RCA
- RFs: HTN, smoking, high cholesterol/lipids, obesity, DM, FH, age (>45 for men, >55 for women), elevated CRP, metabolic syndrome, oral contraceptive use, estrogen deficiency
- Sx: CP, crushing pain, substernal SOB, nausea, upper abdominal pain, sudden death, fatigue, arm/shoulder/neck/back/jaw pain, dyspnea on exertion
- Labs: lipid panel, CMP, CBC, TSH, troponin/CKMB, EKG(ST depression indicates anginal episode, Q waves indicate previous MI)
- Dx tests: exercise stress test(horizontal or downsloping ST depression 1mm or greater is a positive test), echo(can show wall motion abnormalities) , ejection fraction, cardiac catheterization with coronary angiography
- Tx: B-blockers(first line therapy to reduce anginal episodes and improve exercise tolerance because they decrease heart rate and contractility), ASA, nitrates(vasodilators so decrease myocardial demand), HTN meds, statins (for regression of atherosclerosis), angioplasty(PTCA/balloon), PCI(stents; used on stenotic lesions of 70% or greater), CABG
- CABG= coronary artery bypass grafting
- Indications: left main disease, 2 or more affected vessels, unstable or disabling angina, postinfarct angina, coronary artery rupture/dissection/thrombosis after PTCA.
- Internal mammary pedicle graft and saphenous vein free graft are used most often
- Complications: hemorrhage, tamponade, MI, dysrhythmias, infection, graft thrombosis, sternal dehiscence, stroke
- Give ASA and B-blockers after operation
9
Q
Catheterization
A
- Gold standard dx test for CAD
- catheter is inserted in the femoral or radial artery and threaded up to the coronary arteries
- injection of contrast dye into the coronary arteries allows for visualization and quantification of stenotic lesions
- Risks: substantial radiation exposure and risk or contrast-induced nephropathy
10
Q
Aortic Stenosis
A
- Destruction and calcification of valve leaflets resulting in obstruction of left ventricular outflow–>pressure overload on the LV–>LVH
- Etiology: calcification, rheumatic fever, degenerative
- Sx: angina, dyspnea, exertional syncope, CHF, crescendo decrescendo systolic ejection murmur, S4, paradoxical splitting of S2, left ventricular heave or lift
- Workup: CXR, EKG, echo, cardiac cath
- Surgical Tx: valve replacement with tissue or mechanical prosthesis. Indicated if pt is symptomatic or valve cross sectional area is 50mmHg.
- Mechanical valves are more durable but require lifetime coagulation.
- If not a good surgical candidate: balloon aortic valvuloplasty.
11
Q
Aortic Insufficiency
A
- Incompetency of the aortic valve(regurgitant flow)
- Etiology: bacterial endocarditis, rheumatic fever, annular ectasia
- RFs: bicuspid aortic valve, connective tissue disease
- Sx: palpitations, dyspnea, orthopnea, fatigue, angina, increase in diastolic BP, decrescendo high pitch diastolic murmur, austin flint murmur, increased pulse pressure
- Dx: CXR, echo, catheterization
- Tx: aortic valve replacement. Vasodilators(nifedipine, ACEIs)-will delay the need for surgery
- Indications for surgery: symptomatic pt, LV dilatation, decreasing LV function, decreasing EF(less than 55%), acute onset
12
Q
Mitral Stenosis
A
- Calcific degeneration and narrowing of the mitral valve
- RFs: rheumatic fever
- Sx: dyspnea, SOB at night, pulmonary edema, increased left atrial pressure, hemoptysis, hoarseness, palpations, crescendo diastolic rumble murmur, opening snap heard after S2, irregular pulse, stroke
- Dx tests: echo, cath
- Indications for intervention: symptomatic, pulmonary HTN, mitral valve area <1cm/m squared, recurrent thromboembolism
- Tx: open heart surgery, balloon valvuloplasty, valve replacement
- Medical tx: diuretics
13
Q
Mitral Insufficiency(regurgitation)
A
- Incompetence of the mitral valve–>blood regurgitated into the LA during systole–>volume overload on LA, LV
- Etiology: mitral valve prolapse, rheumatic fever, post MI due to papillary muscle dysfunction/rupture, ruptured chordae
- Sx: often insidious; dyspnea, palpitations, fatigue, holosystolic murmur, S3
- Dx: echo, EKG
- Indications for treatment: symptomatic, LV>45mm
- Medical tx: afterload reduction with ACEIs/ARBs
- Tx: valve replacement, annuloplasty(suture prosthetic ring to the dilated valve annulus)
14
Q
Tricuspid Stenosis
A
- Narrowing of tricuspid valve(RA->RV)
- Etiology: occurs with mitral valve stenosis
- RFs: valve repair, carcinoid syndrome, female
- Sx: hepatomegaly, jaundice, JVD
- Dx: PE, EKG shows RAE, echo
- Tx: salt restriction and diuretics to diminish hepatic congestion, valve replacement
- May be progressive causing Right heart failure
15
Q
Tricuspid Insufficiency
A
- Inability of tricuspid valve to stay closed during systole–>blood reenters RA
- Etiology: rheumatic fever, pulmonary HTN
- Sx: fatigue, peripheral swelling, weakness, decreased urine output
- Dx: holosystolic murmur that is intensified during inspiration
- Tx: diuretics, tricuspid annuloplasty or valve replacement
16
Q
Pulmonary Stenosis
A
- Narrowing of pulmonary valve which increases resistance to RV outflow, raises the RV pressure, and limits pulmonary blood flow
- Etiology: congenital heart disease, rheumatic fever, malignant carcinoid tumor
- Sx: decreased blood oxygenation, weakness, fatigue, S4
- Dx: JVD, cyanosis, RVH, echo is dx test
- Tx: balloon valvuloplasty, vlave replacement
17
Q
Pulmonary Insufficiency
A
- Inability of pulmonary valve to stay closed during diastole
- Etiology: pulmonary HTN, tetrology of fallot, infective endocarditis, carcinoid syndrome
- Sx: usually asx
- Dx: decrescendo diastolic murmur, RVH, echo is dx test
- Tx: valve replacement rarely needed
18
Q
Mitral Valve Prolapse
A
- Most commonly seen in thin women
- Etiology: prolapse or billowing of either mitral leaflet
- Sx: nonspecific; CP, palpitations, fatigue
- Dx: mid-systolic “click”, echo can confirm dx
- May progress to mitral regurgitation
- Tx usually not necessary. Valve repair>valve replacement.
19
Q
Penetrating Trauma
A
-Gunshot/stab wound: CXR, FAST exam, chest tube, +/- OR for sub-xiphoid window, If blood returns=sternotomy to assess for cardiac injury
20
Q
Blunt Trauma
A
-
21
Q
Aortic Aneurysm
A
- Etiology: atherosclerosis, connective tissue disease
- DDx: aortic dissection
- Sx: most are asx. CP, stridor, hemoptysis, recurrent laryngeal nerve compression(hoarse voice). Rupture= sudden onset CP with radiation to the back.
- Most commonly discovered on routine CXR(widened mediastinum)
- Dx tests: CXR, CT, MRI, aortography
- Indications for treatment: >6cm in diameter, symptomatic, rapid increase in diameter, rupture
- Tx: replace with graft, open or endovascular stent
- Complications: paraplegia, anterior spinal syndrome(paraplegia, incontinence, pain and temp sensation loss)
22
Q
Aortic Dissection
A
- Separation of the walls of the aorta from an intimal tear and disease of the tunica media–>forms a false lumen
- Etiology: HTN (most common), marfan’s, bicuspid aortic valve, coarctation of the aorta, cystic medial necrosis, proximal aortic aneurysm
- DeBakey Type I: ascending and descending
- DeBakey Type II: ascending only
- DeBakey Type III: descending only
- Stanford Type A: ascending +/- descending
- Stanford Type B: descending only
- Sx: abrupt onset of severe CP most often radiating to the back(intrascapular region), “tearing pain”, pulse discrepancy in extremities
- Sequelae: cardiac tamponade (Beck’s triad= distant heart sounds, JVD, decrease in BP), aortic insufficiency, aortic arterial branch occlusion/shearing leading to ischemia in the involved circulation
- Dx tests: CXR (widened mediastinum, pleural effusion), TEE(trans esophageal echo), CTA, aortography
- Tx DeBakey Types I and II and Stanford Type A: surgical-open the aorta at the proximal extent of dissection and then graft to intimal flap and adventitia circumfrentially.
- Pre-op tx: Control BP with sodium nitroprusside and B-blockers(decrease shear stress)
- Post-op tx: control BP, monitor aortic size
- Tx DeBakey Stage III and Stanford Stage B: control BP, no surgery unless rupture or significant occulusions
23
Q
Arterial Embolism/Thrombosis
A
- Acute Arterial Occlusions: acute occlusion of an artery usually due to embolization. Other causes are thrombosis and vascular trauma.
- Sx: 6 “P’s”: pain, paralysis, pallor, paresthesia, polar, pulselessness
- Arterial occlusion from embolus presents with acute onset pain
- Immediate pre-op management: anticoagulate with IV heparin, angiogram
- Sources of emboli: heart(AFib), aneurysms, atheromatous plaque
- Most common site or arterial occlusions by an embolus= common femoral artery
- Dx: angiogram, EKG, echo
- Tx: surgical embolectomy via cutdown and fogarty balloon
- Complications: compartment syndrome, hyperkalemia, renal failure, MI
24
Q
Carotid Disease/stenosis
A
- Sx: amaurosis fugax(temporary monocular blindness), TIA, RIND(reversible ischemia neurologic deficit), CVA
- Non-invasive evaluation: carotid US/doppler
- Invasive evaluation: angiogram
- Surgical Treatment: Carotid EndArterectomgy(CEA)-removal of diseased intima and media of the carotid artery often performed with a shunt in place.
- Indications for CEA in asx pt: carotid artery stenosis >60%
- Indications for CEA in sx pt: carotid artery stenosis >50%
- Need to perform angiogram and CT scan in sx pts before CEA
- Complications: stroke, MI, hematoma, wound infections, hemorrhage, hypo/hypertension, thrombosis, vagus nerve injury, hypoglossal nerve injury, intracranial hemorrhage
- Post-op medication: ASA
25
Peripheral vascular ulcer
- Found mostly along medial distal leg
- Etiology: Venous valves malfunction--> not pumping blood properly so it pools
- Sx: Charcot's foot in DM(dry, deformed foot, painless, plantar/lateral aspect of foot), absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis
- Dx: ABI(ankle to brachial index; ratio of systolic BP at the ankle and arm; 1 or greater is normal, <.4 is rest pain), angiogram is gold standard
- Tx: occlusive dressings, multilayer compression dressings, debridement, wound vac, surgery(ligation of superficial venous perforators, wound revision with skin graft)
- Indications for surgery: severe claudication, tissue necrosis, infection, rest pain
26
Peripheral vascular ischemia
- Dry gangrene: dry necrosis of tissue w/o signs of infection
- Wet gangrene: moist necrotic tissue with signs of infection
- Blue toe syndrome: intermittent painful blue toes or fingers due to microemboli from a proximal arterial plaque
- RFs: smoking, HTN, hyperlipidemia
- Sx: intermittent claudication, ischemic rest pain, skin ulceration, gangrene, loss of hair, muscle atrophy
- Dx: doppler US, ABI, MRA
- Tx: stop smoking, exercise, beta blockers, statins, ACEIs, percutaneous transluminal angioplasty(PTA), endarterectomy, bypass (FEM-POP), amputation(indicated with irreversible ischemia, necrotic tissue, severe infection, severe pain with no bypassable vessels)
27
Peripheral Vascular Venous Thrombosis
- Swelling/inflammation of a vein usually caused by a blood clot
- DVT and SVT
- Etiology: blood clot
- RFs: being hospitalized, immobile, Virchows triad(vascular injury, hypercoagubility, stasis), pregnancy, OCPs, hx DVT, surgery, sepsis, obesity, malignancy
- Sx: inflammation, swelling, pain, redness, warmth, tenderness, Homan's sign(calf tenderness with dorsiflexion)
- Dx: Doppler US is TOC, venography
- Tx: anticoagulation with heparin and then warfarin for 3-6 mos, IVC filter in pts with contraindication to anticoagulation
28
Varicose Veins
- Swollen twisted veins with abnormal collection of blood
- Etiology: hereditary, distention of vein prevents valve leaflets from closing leading to incompetence
- RFs: after pregnancy, prolonged standing or heavy lifting
- Sx: asx, aching discomfort/pain, dilated tortuous superficial veins in LE, edema, pigmentation, stasis ulcers
- Dx: clinical, Doppler US
- Tx: elastic graduated compression stockings, raise legs at rest
- Surgical Tx: endovenous ablation, great saphenous vein stripping, phlebectomy, compression sclerotherapy
29
Cardiac Tamponade
- Bleeding into the pericardial sac resulting in constriction of heart which decreases ventricular filling resulting in decreased cardiac output
- Rate of fluid accumulation is important
- Etiology: trauma(stab wounds), iatrogenic, pericarditis, post MI with free wall rupture
- RFs: pericardial effusion, pericarditits, malignancy, SLE, TB, trauma
- Sx: tachycardia, shock, pulsus paradoxus(>10mmHg drop in arterial pressure during inspiration), Kussmaul's sign(JVD with inspiration), Beck's triad (hypotension, muffled heart sounds, JVD)
- Dx: echo(RA and RV diastolic collapse), CXR, EKG
- Tx: Aggressive volume expansion with IVF, pericardiocentesis, pericardial window-if blood returns then median sternotomy to r/o and treat cardiac injury
30
Pericardial Effusion
- Rate of accumulation determines degree of hemodynamic instability
- Etiology: any cause of acute pericarditis that can lead to exudation of fluid into the pericardial space
- Sx: fatigue, chest heaviness, dyspnea, palpitations, cough, syncope, tachycardia, decrease in pulse pressure, hypotension, JVD, muffled heart sounds, pulsus paradoxus, soft PMI, dullness at L lung base, pericardial friction rub
- Dx: CXR, EKG
- Tx: echo guided percutaneous pericardiocentesis under local anesthesia, O2, volume expansion
31
Cardiogenic Shock
- Cardiac insufficiency. LV failure resulting in inadequate tissue perfusion
- Etiology: MI, papillary muscle dysfunction, massive cardiac contusion, cardiac tamponade, tension pneumothorax, cardiac valve failure
- Sx: dyspnea, rales, pulsus alternans, loud S2, gallop rhythm
- hypotension, decreased cardiac output, elevated CVP/wedge pressure, decreased urine output, tachycardia
- CXR: pulmonary edema
- Tx: CHF-diuretics, afterload reduction(ACEIs), LV failure due to MI- pressors, afterload reduction
- Intra-aortic balloon pump and ventricular assist device as a last resort
32
Cardiac neoplasms
- Most common benign lesion: myxoma in adults
- Most common malignant tumor in kids: rhabdomyocsarcoma
- Most common location: LA with pedunculated morphology
- Sx: dyspnea, emboli, fatigue, fever, syncope, palpitations, malaise, low pitched diastolic murmur
- Dx: elevated ESR, CXR, MRI, EKG, TEE
- Tx: treat arrhythmias, beta blockers, surgical resection of tumor, heart transplant
- Primary cardiac tumors are rare; most are mets from lung, breast, skin, kidney, lymphoma
Surgery Rotation
flashcards
Decks in class (10)
# Cards
