1
Q
A goosen punch is used to
- A. prepare the aorta for graft placement
- B. prepare the coronary artery for placement
- C. clamp the vena cava
- D. knock out the scrub
A
prepare the aorta for graft placement
2
Q
A Javid Shunt is used to
- Provide flow to the heart
- Provide flow to the carotid
- Provide flow to the brain
- Provide flow to the leg
A
Provide flow to the brain
3
Q
What clamp is used to occlude the common carotid
- Satinsky
- DeBakey Angled Vascular
- DeBakey Aorta
- Patent Ductus
A
DeBakey Angled Vascular
4
Q
What is used to block the vagus nerve during a carotid edarterectomy
- Bovie
- Bi-polar
- 1% Lidocaine
- nothing
A
1% Lidocaine
5
Q
The vein frequently harvested for autograft in a CAB is the
- A. radial
- B. femoral
- C. saphenous
- D. basilic
A
C. saphenous
6
Q
The __ is considered the most important coronary artery.
- A. RCA
- B. PDA
- C. LAD
- D. circumflex
A
C. LAD
7
Q
The ? portion of the carotid artery is unclamped last during a carotid endarterectomy.
- A. internal
- B. external
- C. common
- D. uncommon
A
A. internal
8
Q
The two atrioventricular valves are the
- A. mitral and aortic
- B. tricuspid and mitral
- C. aortic and pulmonic
- D. pulmonic and tricuspid
A
B. tricuspid and mitral
9
Q
Common areas for collection of atheromatous plaque are
- A. bifurcations
- B. veins
- C. teeth
- D. capillaries
A
A. bifurcations
10
Q
The replacement of the aortic valve with an autologous pulmonary valve, and replacment of the pulmonary valve with a cadaver pulmonary valve is known as a
- A. AV-PV replacement
- B. Ross procedure
- C. DeBakey procedure
- D. Cooley procedure
A
B. Ross procedure
11
Q
Which medication is used intraoperatively to prevent clot formation?
- A. papaverine
- B. protamine
- C. streptokinase
- D. heparin
A
D. heparin
12
Q
The heart is stopped to perform which anastomosis?
- A. proximals
- B. distals
- C. doesn’t matter
- D. A and B
A
B. distals
13
Q
The antagonist to heparin sodium is
- A. epinephrine
- B. mannitol
- C. sodium bicarbonate
- D. protamine sulfate
A
D. protamine sulfate
14
Q
The descending aorta terminates at the level of the fourth lumbar vertebrae, dividing into
- A. two saphenous arteries
- B.two femoral arteries
- C. internal and external iliac arteries
- D. two common iliac arteries
A
D. two common iliac arteries
15
Q
All of the following vessels branch off the aortic arch except the
- A. left subclavian artery
- B. brachiocephalic artery
- C. left common carotid
- D. coronary arteries
A
D. coronary arteries
16
Q
During a AAA, the posterior wall of the aneurysm is preserved to
- A. increase the size of the aortic lumen
- B. prevent graftenteric fistula formation
- C. decrease thrombus formation
- D. for historic reasons
A
B. prevent graftenteric fistula formation
17
Q
Equipment needed in the room for a CAB include all except
- A. taylor freeze
- B. defibrillator
- C. nitrogen tank
- D. andrews table
A
D. andrews table
18
Q
During a AAA, blood is collected and reinfused to the patient via
- A. cardiopulmonary bypass machine
- B. autotransfusion machine (cell saver)
- C. pall blood filter unit
- D. venodyne device
A
B. autotransfusion machine (cell saver)
19
Q
The usual heparin dose for heparinized saline is
- A. 1000u heparin/500cc saline
- B. 1000u heparin/100cc saline
- C. 5000u heparin/100cc saline
- D. 1000u heparin/1000cc saline
A
B. 1000u heparin/100cc saline
20
Q
The anatomic structure indicated is the
- A. Right atrium
- B. Left atrium
- C. Right ventricle
- D. Left ventricle
A
D. Left ventricle
21
Q
The anatomic structure indicated is the
- A. Right atrium
- B. Left atrium
- C. Right ventricle
- D. Left ventricle
A
A. Right atrium
22
Q
A doppler is used to
- A. visually verify patency of vessel
- B. audibly verify patency of vessel
- C. defibrillate the heart
- D. verify valve placement
A
B. audibly verify patency of vessel
23
Q
Which type of suture is normally used for end to side vessel anastomosis?
- A. prolene; single armed
- B. nylon; single armed
- C. prolene; double armed
- D. ethibond; double armed
A
C. prolene; double armed
24
Q
During a CAB, the LIMA is most frequently grafted to the
- A. right coronary artery
- B. left anterior descending
- C. circumflex
- D. posterior descending
A
B. left anterior descending
25
The anatomic structure indicated is the
* A. Tricuspid valve
* B. Mitral valve
* C. Aortic valve
* D. Pulmonic valve
B. Mitral valve
26
What is known as the "pacemaker of the heart"?
* A. SA node
* B. AV node
* C. perkinji fibers
* D. bundle of his
A. SA node
27
The most common position for a CAB with SVG is
* A. Supine
* B. Modified recumbant
* C. Low lithotomy
* D. Left Lateral
B. Modified recumbant
28
Atherosclerotic aneurysms are most commonly found in the
* A. ascending aorta
* B. descending thoracic aorta
* C. abdominal aorta
* D. circle of willis
C. abdominal aorta
29
The anatomic structure indicated is the
* A. Tricuspid valve
* B. Mitral valve
* C. Aortic valve
* D. Pulmonic valve
D. Pulmonic valve
30
An abnormal localized dilatation of a blood vessel is known as
* A. atherosclerosis
* B. coronary artery disease
* C. aneurysm
* D. varicose vein
C. aneurysm
31
Cardiopulmonary bypass is used to take the place of the following functions of the human body.
* A. to heat and cool the blood
* B. to pump the blood through the body, to provide O2 to the blood, to heat or cool the blood going to the body, and remove waste and foreign bodies from the blood
* C. provides the same function as the heart and the lungs, plus has the ability to also heat or cool the blood
* D. B & C
D. B & C
32
Antegrade delivery of cardioplegia is obtained by
* A. infusing through the venous cannula
* B. infusing through the coronary sinus
* C. infusing through the aortic root cannula
* D. infusing through the aortic cannula
• C. infusing through the aortic root cannula
33
During CPB, the blood is returned to the body from the heart-lung machine through the
* A. coronary suction line
* B. aortic cannula
* C. superior and inferior vena cava cannulas
* D. central venous line
B. aortic cannula
34
Which suture would be used to close the graft on the iliac artery of a AAA
* 4-0 Prolene RB-1
* 6-0 Prolene BV-1
* 3-0 Prolene SH
* 5-0 Ethibond RB-1
4-0 Prolene RB-1
35
Which instrument would be used as a partially occluding vascular clamp.
* A. glover
* B. patent ductus
* C. satinsky
* D. oschner
C. satinsky
36
The item pictured is a:
* A. Grafting punch
* B. Hole punch
* C. Aortic punch
* D. Two ring punch
C. Aortic punch
37
The pictured item is used for
* A. Placement around mechanical valve
* B. Placement around aortic grafts
* C. Throwing around a pole
* D. Retracting valve leaflets
B. Placement around aortic grafts
38
The type of anastomosis shown is known as a
* A. End to end
* B. Side to side
* C. End to side
* D. Sequential
D. Sequential
39
The instrument shown is a(n)
* A. Sickle knife
* B. Doyen raspatory
* C. Valvulatome
* D. Finochetto blade
• C. Valvulatome
40
An incision is made into the vessel with a #11 KB and extended with
* A. Cooley Scissors
* B. Metzenbaum Scissors
* C. Jorgensons Scissors
* D. Potts Scissors
D. Potts Scissors
41
The items pictured are called
* A. Suture boots
* B. Suture tips
* C. Peanuts
* D. Tip covers
A. Suture boots
42
The items pictured are used to
* A. Retract ducts
* B. Retract vessels
* C. Tournequit vessels
* D. All of the previous
• D. All of the previous
43
Functions of the Circulatory System
* Transportation
* carrying RBCs to circulate system, transporting hormones, removes metabolic waste
* Regulation
* regulate water and salt in system, works closley with endocrine and nervous system, pH buffer
* Protective
* WBCs kills bacteria, clotting factor
44
Mediastinal Space
* Heart and lungs sit in along with esophagus, trachea, thymus
* mediastintomy= surgical opening of mediastinum
* Borders:
* anterior=sternum
* Posterior=vertebre
* Superior=first rib
* Inferior=diaphragm
45
Two types (2) of circulation
1. Pulmonary Circulation (cardiothoracic)
1. low pressure system
2. Systemic Circulation (peripheral vascular)
1. high pressure system
46
Arch Vessels/Great vessels
* blood to brain/head
* brachiocephalic trunk
* Left common carotid artery
* Left subclavian artery
47
Valves of the Heart
* Aortic valve- high pressure
* Pulmonary valve- low pressure
48
Valves
* Note: annulus around each valve- little white rings around valve, what surgeons suture into
* Note: coronary arteries just superior to aortic valve.- pretty superficial, you are outside of the heart when working on these
49
Label
1. Superior vena cava
2. Right Atrium
3. Tricuspid valve
4. Right Ventricle
5. Papillary muscles
6. aortic arch
7. pulmonary artery (not oxygenated blood)
8. Left Atrium
9. Mitral valve/ Bicuspid valve
10. Ventricular septum
11. Left Ventricle
50
Heart Wall & Pericardium
* Heart Wall is made of three distinct layers:
* 1. Epicardium or Fibrous pericardium
* Outer layer
* double layer with fluid in pericardial space
* 2. Myocardium
* Middle & Muscle layer
* 3. Endocardium
* Inner layer, lines heart, valves and continues into blood vessels
* smooth surface not that holy, very thin
51
Cardiac Cycle
* Diastole- resting, filling
* Systole- pumping ventricles, going out, systemic
* left ventricle= work horse
* volume 120mls when filled
* 120-50mls= 70mls went out= stroke volume
52
Pericardial space can have inflammation
* Pericarditis- increase of fluid in the space
* Pericardial Effusion- bad, can impede vessels
* fluid increase impair cardiac filling in ventricles
* Cardiac Tamponade- lots of fluid- heart can't pump the space is too full, true emergency
53
3 characteristics of heart tissue
1. initiate its own beat
2. beats on a regular basis- 80 bpm
3. conduction-rapid
54
Cardiac cycle & other heart monitoring.
* this is what they are looking at when they put an art line in
55
Electrical Activity of the Heart
* Sinoatrial Node (SA)-- pacemaker of the heart
* Atrial-Ventricular node (A-V)
* Bundle of His
* Right and Left Bundle Branches
* Purkinje fibers
Don't want to mess up electrical pathway
56
Dysrhythmias
* Supraventricular Dysrhythmia
* produced by the SA node, Atria, AV node, or Junctional Bundle.
* not life threatening
* Ventricular Dysrhythmias
* produced by Ventricles
* lethal
* ventricular fibrilation
* Ectopic pathway- outside of normal pathway
57
Starlings law of the Heart
* If the ventricles receive an increased volume of blood, they can respond by contracting more forcibly. This is an important selfregulatory mechanism within the muscles
* important for heart transplant
58
Vascular system
* Arteries \>\> Arterioles \>\> Capillaries \>\>Venules \>\> Veins
59
Artery layers
60
Vein layers
* veins have valves out in periphery except inferiror and superior vena cava
61
Arteriole
* small
* nerves surrounding it
62
Capillaries
* no nerves on capillaries
63
Label arteries
1. Brachial Artery
2. Acsending Aorta
3. Subclavian
4. Common carotid
5. Brachiocephalic
6. Descending Aorta
7. Coronary artery
8. Abdominal aorta
9. Common iliac
10. Femoral artery
64
Veins Label
1. Brachial vein
2. Brachiocephalic
3. Jugular
4. Subclavian
5. Superior vena cava
6. Coronary veins
7. Inferior vena cava
8. iliac veins
9. femoral vein
10. Greater saphenous vein
65
Veins
* Venous bleeding **difficult to control**; more fragile than arteries
* Semilunar intimal folds: valves prevent backflow
* Fewer nerve fibers
* in surgery the blood will well up from the bottom and the surgeon can't find the origin of the bleeding if nicked.
66
Neurologic Control of the Heart
* Baroreceptors
* regulation of cardiac output and blood pressure
* Chemoreceptors
* chemical sensitive. one @ carotid and aortic body
* oxygen and CO2
* Cardiovascular Regulatory center in the Medulla Oblongata- controls heart rate
* 1. Cardio**inhibitor**--Vagus nerves
* 2. Cardio**accelerator**-
67
* Ischemia
* Infarction
* Collateral circulation
* low blood flow (an inadequate blood supply to an organ or part of the body, especially the heart muscles)
* zero bloodflow, tissue will die
* is the alternate circulation around a blocked artery or vein via another path, such as nearby minor vessels
68
* circumflex
* supplies left atrium
* Left Anterior Descending
* supplies left ventricle
* "widow maker" if this gets blocked, pt. dies
* Diagonal- 5-7 of them
* Post Descending
* supplies posterior Right ventricle
* Acute marginal
* supplies right ventricle
* Atrioventricular
* supplies right atrium
* Sinus node (SA node)
* supplies right atrium
69
Right coronary artery (RCA) circulation
* S-A node
* Acute marginal
* Posterior Descending Artery (PDA)
* Atrioventricular
70
Left Coronary Artery (LCA) circulation
* Left Anterior Descending (LAD) artery
* Diagonal(DX)
* Left Circumflex Artery (CX)
* Obtuse Marginal (OM)
71
Posterior view of the heart
* Where we put the retrograde cardioplegic cannulae or tube in surgery
72
Blood Flow
* Laminar flow
* Turbulent flow: evidenced by bruit (sound @ the bifercation at carotid)
* Flow depends on viscosity (thickness), vessel wall resistance, peripheral resistance of the arterioles
* Pressure gradient
* Negative pressure in right ventricle assists in venous return Poiseuille’s Law
73
Poiseuille’s Law
* Blood pressure dependent on:
* Radius
* Length
* Pressure
* Viscosity
* As resistance= heart works harder
74
Arterial Blood Pressure
* Result of intermittent ejection of blood from the left ventricle into the Aorta.
* Normal Range 120/80
* Two (2) factors that affect the pulse pressure:
* Cardiac Output
* Peripheral Vascular Resistance
* the more narrow= heart pumps harder
75
Arterial Pathologies
* Heart Disease
* Hyperlipidemia
* Lipoproteins
* Artherosclerosis
* Venous disorders
* Aneurysms
* Aortic
* Dissections
* Arterial disease of extremities
* Femoral-Pop
76
Myocardial & Endocardial Disease
* Myocarditis
* inflammation of muscle of heart due to virus/infection
* Cardiomyopathy
* High BP-- secondary to infection, may be congenital (big range)
* Endocarditis
* 2 things present
* Bacteria
* Damage to endothelial lining
* ex: IV drug user with dirty needle, heart valve replacement
* Coronary Heart Disease (CHD)
* occlusions
* ischemia in coronary arteries
77
Angina
* Chest pain or pressure that is associated with myocardial ischemia.
* Three (3) types
* Stable (Classic) Angina- excersise, exertion
* Variant Angina- coronary spasms
* Unstable Angina- pt. at rest with angina, plaque disruption
* Treatment: Nitroglycerin. Goes directly to heart that's why you put it under the tounge. causes vasodilation of coronary arteries
78
Arterial Pathologies Cont.- Lipoproteins
* Lipoproteins carry cholesterol and triglycerides
* Five (5) classes of Lipoproteins
* 1. Chylomicrons
* 2. VLDL -Very Low-Density Lipoproteins
* **3. HDL- High Density Lipoproteins- can lift up the low ones and take to the liver to get rid of higher than 40**
* 4. IDL-Intermediate Density Lipoproteins
* **5. LDL- Low Density Lipoproteins- bad ones want lower than 180**
79
Risk Factors for Atherosclerosis
* Firmly established
* Hypercholesterolemia
* Cigarette smoking
* Hypertension
* Diabetes mellitus
* Relative factors
* Advanced age
* Male gender
* Hypertriglyceridemia
* Hyperhomocysteinemia
* Sedentary lifestyle
* Family history
80
Acute Arterial Insufficiency
* Inadequate blood flow through the arteries
* Acute occlusion
* Embolic disease- embolus could be air, fat, plaque
* Rupture of unstable atherosclerotic plaque
81
Six P’s of Acute Occlusion
* Sudden severe **P**ain
* Pulselessness
* Paresthesia (numbness)
* Paralysis
* Pallor (pale)
* Poikilothermia (cold body temp)
82
Chronic Arterial Insufficiency
* Chronic inadequate blood flow through the arteries
* Deposition of calcium and cholesterol on the walls of the artery
* Natural part of aging: elasticity of arteries diminishes
* Atherosclerosis obliterans
83
Cerebrovascular Disease and Stroke
* Right and left carotid and vertebral arteries supply the brain
* Stroke: cerebrovascular accident (CVA)
* can give drugs to break up plaque
* streptokinase- break up clots
* Leading cause of death in the United States
84
Peripheral Vascular Disease
* Claudication (pain while walking) distal to obstruction
* Rest pain
85
Acute Venous Insufficiency
| (valves don't work properly)
* Varicous Veins
* Deep vein thrombosis (DVT)-- if clot breaks off could have embolus
* Phlebitis-- inflammation of vein (bacteria)
* Thrombophlebitis-- becuase of a clot
* Virchow’s triad
* Endothelial injury
* Venostasis
* Hypercoagulability
86
If inferior vena cava is blocked...
* it's not that big of a deal, the venous system can get blood back to the heart
87
Greenfield filter
* Inserted into IVC and can catch clots
* why?
* DVT, throwing clots
* Done in radiology under flouro
88
Arterial Pathologies Cont.- Aortic Aneurysms
* May include entire wall of artery or behind an intimal tear.
* Diagnosis: Ultrasound, CT scans, MRI
* Treated with Surgical repair
89
Other Vascular Disorders
* Marfan
* An inherited disorder that affects connective tissue, arteries get weak, tall thin long arms and legs, heart vessels
* Reynaud’s
* A condition in which some areas of the body feel numb and cool in certain circumstances. turns blue intense vasospasm in feet, hands. afeccts young women, hyperactivity of SNS.
* Hypertension- high BP
* Pheocromocytoma
* A hormone-secreting tumor that can occur in the adrenal glands. symptoms include high blood pressure, sweating, rapid heartbeat, and headache
* Coronary Heart Disease (CHD)
* Heart Valve Disease
90
Diagnostic tools & Procedures
| (non-invasive)
* Electrocardiogram
* place 12 leads
* Exercise Electrocardiogram (Treadmill Testing)
91
CARDIAC CATHETERIZATION
* a procedure used to diagnose and treat cardiovascular conditions. During cardiac catheterization, a long thin tube called a catheter is inserted in an artery or vein in your groin, neck or arm and threaded through your blood vessels to your hear
* angiogram- coronary arteries
92
Coronary Angioplasties and Stents
| (done in cath lab)
* PTCA- percutaneous Transluminal coronary angioplasty- guide wire with balloon, presses artery open and a stent is left
* Stents- wire mesh to keep artery open
* Atherectomy-is a minimally invasive endovascular surgery technique for removing atherosclerosis from blood vessels within the body. It is an alternative to angioplasty for the treatment of peripheral artery disease, with no evidence of superiority to angioplasty. grinds away plaque
93
Ejection fraction
* how well the ventricles are working?
* 70ml stroke volume
* 70/120= 58% Ejection Fraction (EF)
* 58% is normal
* below 40% abnormal/bad left ventricle
94
Diagnostic tools & Procedures
* Electrophysiology
* Pacemaker \>\>\>
* Radio frequency ablation
* Internal defibriltor \>\>\>\>\>
* Holter Monitor- simple heart monitor
95
Surgical Procedures
* Coronary Artery Bypass
* MVR/AVR
* Ross procedure
* Abdominal Aortic Aneurysms
* Steps in an Emergency AAA
* Carotid Endarterectomy
96
Four (4) Purposes of Heart Surgery:
1. Correct acquired or congenital anatomic abnormalities. (usually pedis)
2. Repair or replace defective valves.
3. Revascularize ischemic myocardium
4. Improve or assist ventricular function.
97
Coronary Artery Bypass Graft (CABG)
* The surgery is done to reroute, or "bypass," blood around clogged arteries and improve the supply of blood and oxygen to the heart.
* bypass with perfusion machine
98
Bypass Or Cardiovascular Perfusion
* This is a specialized field in the allied heath area. Most patients who under go heart surgery are placed on a Bypass machine. What this does is bypass the heart- The machine oxygenates the blood and circulates the blood through the systemic circulation.
* will cool pt. down
* hypothermia is induced in cardiac surgery
* oxygen consumption reduced by 50%
* Pt. given heprin before put on this machine given by anesthesia
* ACT= Active Clotting Time- test to make sure the blood is thinned out.
99
Excision of greater saphenous vein
* A. Traditional
* B. Endovascular Vein harvest incision
* C. Endoscopic Vein Harvest
100
Grafts
* Internal mammary artery- get from underneath sternum
* This would be a triple bypass (or 3 jumps)
101
* Rultract Retractor used to elevate sternal border for exposure of internal mammary artery
102
* papaverine is injected into artery to keep it from constricting
103
Anastomosis
* done with prolene
104
Equipment needed for Heart Surgery
* Cardiac Tray
* Oscillating Saw
* Hemoclips
* Debibrillator/paddles
* Cardioplegia administration set
* KB’s #10, 15, 11, beaver
* Cell Saver tubing
* Bone wax
* Doppler
* Suture boots
* Felt & Pledgets
* Needle counter
* Asepto
* Chest tubes/Pleurevac
* Bovie
* Heparinized saline
* Hemostatic agents (use only after bypass)
* Thrombin
* Surgicel
* Taylor Freeze
* CO2 blower
105
Medications
* Heparin- all vascular cases anticoagulant
* Protamine sulfate- reverses heparin
* Papaverine HCl- vasodilator into IMA
* Cardioplegic solution- stops heart high dose of potassium
* Topical hemostatic agents- only after off bypass
* Antibiotic administration
106
* Arterial Cannulae
* pointed toward arch vessels
* sits in aorta
* has to be air free! goes in first bubble can cause stroke
107
* Venous Cannulae
* Goes into rt. atrium (dog ear)
* drains all blood.
* can have air
108
* Antegrade cardioplegic cannulae
* clamp aorta
* purstring suture
* sits below clamp
109
* Retrograde cardioplegic cannulae
* this is a reverse flow. There might be a blockage that is blocking the cardioplegic flow
* Goes in the coronary sinus
110
3 C's of stopping the heart
1. Cross clamp
2. Cardioplegic solution
3. Cold Slush
111
Cannulation of the heart
112
Supplies for CABG
* Vein stripper- have to strip veins or mark which way they are going so they can be flipped
* Sternal saw (make sure and test it when pt. not in room)
* Internal Defibrillator paddles
* suture boots
* goosen punch- hole in aorta for saphenous vein graft
* Horse shoe markers to mark saphenous vein grafts
113
Intra-Aortic Balloon Pump (IABP)
* assists left ventricle
* sits in aorta
* helps ventricle rest
* temporary
114
Chest Drainage System:
* restores (-) pressure
* First chamber collects drainage
* second chamber is the water seal
* Third chamber is the suction control.
* always have to have chest tube when chest is open
* \*Never hook up to neptune
115
can you do an off pump cabg?
yes
116
MITRAL Valve
* Mitral stenosis is the **most common acquired valvular lesion**.
* could be caused by Rhumatic fever
* causes pressure to rise in left atrium
117
NATURAL HISTORY OF AORTIC STENOSIS
* 30% of patients with aortic stenosis develop angina
* 20% of patients develop syncope (fainting)
* 50% of patients die within 2 years of onset of symptoms _without intervention_
118
CAUSES OF AORTIC STENOSIS
* Calcification- need to be carfule about calcium supplements
* Congenital bi-cuspid valve
* Congenital uni-cuspid valve
* Rheumatic disease
119
Congenital Abnormalities of aortic valve
bicuspid instead of tri
120
Aortic Valve Replacement (AVR)
* mechanical
* biological
* allograft= from human
* bovine or porcine= cow or pig
* never open valve until it is sized
* handle with proper instruments
121
Replacement vs. annulus repair
* annuloplasty
* made of ethibond- stong braided
122
What does the Ross Procedure involve?
* Ross Procedure uses the patient’s own pulmonary valve to replace the diseased aortic valve.
* The patient’s pulmonary valve is replaced with a cryopreserved cadaveric pulmonary valve.
* Longevity of valve is superior to that of other biologic valves.
* \* better for younger pts
123
Who is the ideal candidate for the Ross Procedure?
* Infants with congenital aortic stenosis
* Older patients with more active lifestyles
* Women of childbearing age
* Athletes
124
Ventricular Septal Defect
* (VSD)
* hole in ventricle
* pt can survive with a smaller hole
125
Tetrology of Fallot
1. VSD
2. Pulmonary Stenosis (narrowing)
3. Hypertrophy of Right ventricle (thickened)
4. Aorta overrides the VSD
126
Patent Ductus Arteriosus (PDA)
* Ductus arteriosus usually closes after birth
* Diagnosis-Murmur, Tachycardia, poor feedings.
* Treatments:
* Indomethacin or Ibuprofen or Surgery
* but drugs can sometimes cause intracardial bleeds
* This should usually close 24-72 hours after birth
* happens a lot in premies
* blood shunts away from lungs
127
AAA Anatomy
* retroperitoneal
* starts at hylus of diaphragm
* biferication @ T12
* most anurysyms happen below renal arteries and below the superior mesenteric artery with feeds the bowel
* anurysym= ballooning out of
128
AAA Diagnosis
* CT
* Plain film X-ray
129
Rupture rates for AAA
* 5-6cm= 25% ruptre rate
* 6-7cm= 35% rupture rate (probably have surgery here)
* above 7 cm= 75% rupture rate
* \*50% mortality rate if ruptured
130
3 things that are looked for or you see after AAA rupture (in ER)
(triad of 3)
1. severe abdominal pain
2. low BP
3. abdomen pulsating
\*Go directly to OR
131
Emergency repair of AAA in OR
* 5 minute set-up
* no count
* cell saver (maybe 2-3 lines)
* watch where knige goes it will be flyin
* get vascular clamp ready
* once they clamp below renals, everyone can kind of calm down
* bair hugger can burn pt. where blood isnt flowing
* need basin to scoop out clots
132
Risk factors for AAA
* smoking
* obesity
* male
* poor diet
* alcohol consumption
* family history
* Age above 65
133
Woven Dacron graft
* If the graft is not pre-clotted you may have to draw blood from pt. and roll the graft around in the pt.s blood/platelets
* also lined with radiopaque material
134
Dissecting Aneurysm
* seperation of the layers in the Aorta where blood is going into the middle layer
* tear in the tunica intima forms
* false lumen
* cause: chronic hypertension
135
Endovascular repair of AAA
* Through a needle puncture or small incision in one or both of your groin arteries and guided by X-ray images, a thin tube (catheter) is inserted and advanced to the aneurysm site.
* A guide wire and an expandable stent graft (a fabric-covered wire frame) are advanced through the thin tube.
* When positioned correctly, the stent graft is allowed to expand within the artery. The wire frame pushes against the healthy portion of the aorta to seal the device in place.
* Once in place, blood flows through the stent graft and cannot enter the aneurysm.
136
Carotid Endarterectomy
* Removal of atheroma (plaque) in the carotid artery
* May use temporary arterial shunt
* argyle (striaght, harder)
* Javid (more flexy)
* May use intraoperative EEG
137
* Sternocleidomastoid muscles cover the internal jugulars and carotid sheaths.
138
Carotids
* internal- to brain
* External- to face
* 1% lido loaded on a syringe and ready to inject into vagus nerve. BP/ HR could go down, this will help
139
Pectus Excavatum
* Sternum is deformed
140
Ventilation
* Mechanically, the act of breathing depends on the fact that the chest is a closed compartment whose only opening to the exterior is the trachea
141
Pulmonary diseases:
* Cystic Fibrosis (CF)
* Pulmonary Hypertension (PPH)
* Cancer
* Chronic Pulmonary Obstructive Disease (COPD)
* Can be caused by Emphysema (ballooning of alvioli)
142
Bronchoscopy
* flexible scope
* have rigid bronchoscope to remove a foreign object in bronchus
* luekentrap- fluid trap hooked to bronchoscope to get washings.
* Carina- where bronchos divides
* not sterile procedure
143
Mediastinoscopy
* have sternal saw in room in case things go bad
* diagnostic procedure taking lymph node biopsy
144
VATS
* (Video Assisted Thoracic Surgery)
* VATS is a minimally invasive surgery in which surgeons operate through 2-4 one inch openings with the direct visualization of the patient’s chest cavity on a television monitor. It is an alternative to an open chest operation but still considered major surgery. Also known as Thoracoscopy
145
What diseases can be treated with VATS?
* Treat blebs on the lung- blisters
* Diagnose and treat fluid around the lungs
* Diagnose and treat fluid around the heart
* Diagnose or stage lung cancer
* Treat lung cancer in patients who can’t tolerate open surgery
* Diagnose and treat mediastinal tumors
* Plueraldesis
* can put talc powder in pluerl space to keep lungs open
146
VATS Advantages: & Disadvantages:
* Advantages:
* Less postoperative pain, shorter hospital stay, lower morbidity rate, smaller incisions, quicker return to work
* Disadvantages:
* yields a smaller sample than open lung biopsy, patient functions with one lung during procedure, possibly resorting to an open procedure
147
VATS Procedure
* VATS does not describe a specific surgical procedure but the technique used to gain access into the chest cavity
148
VATS is used for many other thoracic surgical procedures
* Ligation of the thoracic duct
* Decortication of lung- most common for VATS
* Creation of pericardial window
* Zenker’s diverticulum- herniation of esphagus
* Lobectomy
* Benign esophageal tumors
* Removal of chest wall tumor
* Thoracic sympathectomy- sweaty palms
149
Risk & Complications VATS
* Wound infection
* Bleeding
* Air leak through the lung wall
* Pain or numbness at incision site
* Inflammation of the lungs (pneumonia)
150
VATS set-up
* Variety of sponge sticks
* 5mm/10mm/12mm trocars
* Straight Mayo scissors & Cooley Scissors
* #10 KB on #3 KH
* Camera, TV Monitors, cords
* Biopsy forceps
* Tonsil Hemostats
* Sets: VATS; Thoracotomy and
* chest retractors prn
151
Position for “Open” Thoracotomy?
* Lateral or posterolateral
152
* Bailey rib approximator
* Doyen rib raspatory- elevator to get periosteum off rib
153
Venous access device (two types listed below, but there are more)
* Port-a-cath- more for chemo
* Groshong- more for dialysis
* Central venous catheter placed in the subclavian vein.
* Large bore needle is inserted into the vein a wire is introduced until it reaches the right atrium via SVC
* Catheter inserted & guide wire and sheath peeled away.
154
Atriovenous (AV) Fistula
* end of cephalic vein anastamosed to the side of the radial artery at a site superior to the usually location of the radiocephalic fistula. This tecnique can be useful if the distal radial artery is small or the cephalic vein at the wrist is thrombosed
155
Atriovenous (AV) with graft
* loop fistula
*
156
Arterial Procedures
* Percutaneous transluminal angioplasty
* Femoral–popliteal and femoral–tibial bypass
* Femoral–popliteal bypass in situ
* Femorofemoral bypass
* Embolectomy
157
Pheumothorax
* is defined as air within the pleural space
158
Atelectasis
* means imperfect expansion or incomplete expansion.
159
Emphysema
* is characterized by a loss of lung elasticity and abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles with destruction to the alveolar walls and capillary beds
160
Asthma
* is a chronic inflammatory disease of the airways.
161
Cor Pulmonale
* refers to heart failure resulting from primary lung disease and longstanding pulmonary hypertension
162
Hypoxia
* refers to a reduction in tissue oxygenation. It can result from an inadequate amount of oxygen in the air or disease of the respiratory system
163
Cyanosis
* refers to the bluish discoloration of the skin and mucous membranes.
164
Pleural Effusion
* refers to a collection of fluid in the pleural cavity. The fluid may be a transudate, exudates, chyle, or blood
165
Empyema
* refers to pus in the pleural cavity
166
Chylothorax
* refers to the presence of chyle in the thoracic cavity
167
Hemothorax
* is the presence of blood in the thoracic cavity
168
Pulmonary Emboli (P.E.)
* The obstruction of the pulmonary artery or a branch of it leading to the lungs by a blood clot, usually from the leg, or foreign material causing sudden closure of the vessel. It is a common potentially lethal disease. P.E. usually arises from the thrombi originating in the deep venous system of the lower extremies.
* Remember anytime fluid is in the pleural cavity it is occupying space, which decreases lung volume on the affected side.
169
\*\*Thoracic outlet syndrome
* involving compression of a neurovascular bundle passing between the anterior scalene and middle scalene. It can affect the brachial plexus, and/or the subclavian artery or rarely the vein. It can be corrected by removing the first rib.
170
\*\*Decortication –
* is the surgical removal of fibrinous deposits on the visceral and perietal pleura. FYI: Fibrinous deposits can interfer with function of the lungs.
171
\*\*Collins solution-
* after harvesting of the lung is complete, the trachea is stapled shut, and the donor lung is placed in cold Collin’s solution.
172
Trace blood through the heart
1. Superior Vena Cava/ Inferior Vena Cava
2. Right Atrium
3. Tricuspid valve
4. Right Ventricle
5. Pulmonary Valve
6. Pulmonary Artery ---\>lungs
7. Pulmonary Vein
8. Left atrium
9. Mitral valve
10. Left Ventricle
11. Aortic Valve ----\> systemically to organs
173
Baroreceptors
* Regularion of cardiac outut and blood pressure
* Depression influence- sensitive to elevated BP and incresed HR
* Pressor influence- sensitive to low BP and HR
174
Chemoreceptors
* carotid body
* Aortic body
175
Coronary Arterial Supply
176
Arterial Line
* used to constantly monitory bp and draw blood samples
177
* Duval lung clamp
178
* Haight Rib Retractor
179
* Derra anastomosis clamp
180
Satinsky
| (partial occlusion)
181
DeBakey aorta clamp
182
Peripheral vascular clamp
183
Sarot bronchus clamp
184
Potts scissors
185
Potts tenotomy scissors
186
Diethrich bulldog clamp
Surgical Procedures II
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Decks in class (5)
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