Cardiothoracic Surgery

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Cardiothoracic Surgery

• Hannah Zimmerman, MD
• Surgery Resident

2
Ischemic Heart Disease

• Causes
• Atherosclerosis of the coronary arteries
• Valve disease
• Vasculitis
• Congenital disease
• Anatomy
• dominance of a coronary is defined as that
  coronary that gives off the posterior descending
  ( posterior desc gives off artery to the AV node)
  thus comes into play in heart block.
• right dominance is in 85, left in 10, and mixed
  is in 5

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Pathophysiology of Ischemia

• Ischemia is secondary to a lack of blood flow to
  a region of the heart
• What determines metabolic demand wall tension,
  heart rate, contractility
• Atherosclerotic plaque decreases flow,
  multifocal, multivessel
• Plaque rupture worsening symptoms

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Risk Factors

• HTN
• Smoking
• Hyperlipidemia
• Obesity
• Diabetes
• Family History

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Signs Symptoms

• Fatigue
• Angina
• Dyspnea
• Edema
• Palpitations
• Syncope

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Diagnosis of Ischemia

• EKG
• STEMI is st segment elevation mi and implies
  transmural infarction
• non STEMI is assoc with ST depression and mild
  troponin elevation
• ST elevation in the absence of troponin is angina
  and if it is gt 2mm depression it is an indication
  for immediate angiogram
• Stress Test
• Echocardiography estimated ejection fraction
• Cardiac Catherization angiography, identifies
  sites of lesions, quantifies lesions

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EKG
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Treatment

• Medical ASA, beta blockers, calcium channel
  blockers, ACE Inhibitors, diuretics, nitrates
• PTCA Percutaneous Transluminal Coronary
  Angioplasty/ PCI Percutaneous Coronary
  Intervention
• Surgery CABG Coronary Artery Bypass Grafting

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Coronary Artery Bypass Grafting

• Bypass areas of obstruction of coronary artery
  vessels using internal mammary artery (IMA) or
  reversed saphenous vein
• 3 or more vessels

• Indications
• best candidate for a CABG is someone with bad
  heart function and bad coronaries (diffuse)
  because the medical rx mortality is significantly
  greater than for surgical treatment
• Stable angina, unable to medically manage
• Unstable angina
• Post-infarct angina
• 2-3 vessel disease with decreased LV fxn
• Left Main Disease
• Complications of PTCA stent

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Valvular Heart Disease
http//www.patient.co.uk/showdoc/27000266/
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Mitral Stenosis

• Mitral Stenosis
• Etiology Rheumatic (most common), congenital
• More common in Females
• Pathophysiology
• Mitral leaflets thickened calcified secondary
  to inflammation, can result in fusion (severe
  cases)
• Leads to Pulmonary congestion secondary to
  pulmonary HTN, LA dilatation and decreased CO

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Mitral Stenosis
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Mitral Stenosis
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Mitral Stenosis

• Signs symptoms
• Dyspnea, rales, cough, hemoptysis, systemic
  emboli (stasis of blood in LA), RV failure,
  hoarseness (stretching of the Recurrent laryngeal
  nerve by enlarged LA), irregularly irregular
  heart beat
• Diagnosis
• Low pitched rumble mid diastolic murmur at the
  Apex
• CXR straight left heart border (enlarged LA),
  Kerley B Lines from pulmonary effusion

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Kerley B Lines
http//myweb.lsbu.ac.uk/dirt/museum/cxr-intro.html
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Mitral Stenosis

• Treatment
• Endocarditis prophylaxis
• Heart Failure treatment Diuretic and B Blocker
• Anticoagulation for A Fib
• Surgical Replacement of Valve
• Indications - A Fib, worsening Pulmonary HTN,
  Systemic emboli, infective endocarditis
• mitral stenosis is rarely amenable to repair,
  most of the time replacement is the only long
  term option
• Replacement 5 year survival rate 60-90, 10
  year survival 40-75

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Mitral Insufficiency

• Etiology
• Papillary muscle dysfunction from either ischemia
  or infarction (post MI papillary muscle rupture)
• Rupture of chordae tendinae
• Valve destruction scarring from RHD or
  endocarditis
• Prolapse can progress to incompetence
• Dilatation of the Mitral Annulus from Heart
  Failure

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Mitral Insufficiency

• Backflow into Left Atrium

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Mitral Insufficiency

• Signs symptoms
• Dyspnea, fatigue, weakness, cough, A fib,
  systemic emboli, can lead to pulmonary
  congestion, Right Heart Failure, LA dilation, LV
  overload
• Diagnosis
• Murmur loud holosystolic, high pitched, apical
  radiating into axilla
• S2 split widening secondary to premature
  emptying of LV
• ECHO diseased/prolapsed valve

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Mitral Insufficiency

• Treatment
• Good Prognosis if LV function is preserved
• Medical
• Used until surgery or if patient poor surgical
  candidate
• Diuretics to decreased volume load
• Vasodilators reduce afterload, favors aortic
  flow
• Anticoagulation for A Fib
• Surgical
• Valve repair or replacement
• mitral regurg is best treated by repair which can
  be done sucessfully in about 80 of cases

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Aortic Stenosis

• Etiology
• Degenerative calcific disease (idiopathic or
  older population)
• Congenital
• Bicuspid valve
• Rheumatic heart disease

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Aortic Stenosis

• Pathophysiology
• Obstruction of flow leads to LVH and decreased LV
  compliance, and later LV dilation congestion
• Sign symptoms
• Dyspnea
• Angina syncope especially during exercise,
  PVR decreases, LV pressure remains the same
  because of stenotic valve, CO cannot be maintain
  BP, resulting in syncope, low BP to coronary
  arteries results in angina
• Heart failure

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Aortic Stenosis
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Aortic Stenosis

• Diagnosis
• Loud systolic ejection murmur, crescendo-decrescen
  do, medium pitch
• S4 gallop secondary to reduced LV compliance
• Paradoxical splitting S2
• Narrow pulse pressure
• ECHO diseased valve
• Treatment
• Surgical
• Replacement definitive treatment
• 10 year survival gt 80

http//www.virtualcancercentre.com/uploads/VMC/Dis
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Aortic Regurgitation

• Etiology
• Aortic root dilatation idiopathic, collagen
  vascular disease, marfans syndrome
• Valvular disease RHD, endocarditis
• Proximal aortic root dissection cystic medial
  necrosis (Marfans), syphilis, HTN, Ehlers-Danlos,
  Turners Syndrome
• Degenerative

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Aortic Regurgitation
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Aortic Regurgitation

• Signs Symptoms
• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
• Angina secondary to decreased diastolic
  coronary blood flow due to elevated LV end
  diastolic pressure
• LVF
• Wide pulse pressure
• Hills sign systolic pressure in legs gt 20 mmHg
  higher than in the arms
• Quinckes sign alternating blushing and
  blanching of fingernails when gentle pressure is
  applied
• DeMussets sign rhythmic bobbing of the head
  with the heartbeat

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Aortic Regurgitation

• Diagnosis
• High pitched blowing decrescendo diastolic murmur
  best heard over the right second or third
  interspace
• EKG LVH
• ECHO demonstrates regurgitant valve
• Treatment
• Medical treat LVF afterload reduction such as
  ACE Inhibitor, endocarditis prophylaxis
• Surgical repair or replacement

29
Lung Cancer

• Types
• Small Cell
• Central
• Sensitive to chemotherapy
• Non Small Cell
• Includes squamous, large cell, adenocarcinoma
• Poor response to chemotherapy
• Treatment surgery
• Prognosis Varies

http//adam.about.com/encyclopedia/Lung-cancer-fro
ntal-chest-x-ray.htm
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Lung Cancer

• Leading cause of cancer death in both men and
  women in the US
• Smoking most preventable risk factor
• Other Causes second hand smoke, radon gas,
  asbestos, arsenic, nickel

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Signs Symptoms

• Chronic Cough
• Hemoptysis
• Stridor
• Dyspnea
• Hoareness
• Dysphagia
• Paraneoplastic Syndromes

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Diagnosis of Lung Mass

• CXR Lung Nodule
• stable for 2 years, no further evaluation
• New onset within the last 2 months unlikely
  malignant
• CT Chest location, mediastinal invasion,
  evaluate liver and adrenal glands for metastasis
• Bronchoscopy central location, biopsy
• Thoracentesis evaluate pleural effusions
  suspicious for malignancy

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Lung Cancer
http//www.virtualcancercentre.com/uploads/VMC/Dis
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Lung Cancer

• Small Cell Lung Cancer
• Ectopic peptide ACTH, Gastrin, AVP, Calcitonin
• 80-90 response to radiotherapy
• 50 complete regression with chemotherapy
• Surgical resection NOT indicated

• Non Small Cell Lung Cancer
• Ectopic peptide PTH
• 30-50 response to radiotherapy
• 5 complete regression with chemotherapy
• Surgery indicated
• Subtypes adenocarcinoma, squamous cell, large
  cell

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Thoracic Aortic Aneursyms

• Classification
• DeBakey
• Type I Ascending and Descending Aorta
• Type II Ascending aorta only
• Type III Descending aorta only
• Stanford
• Type A Ascending aorta
• Type B Descending Aorta

http//www.vascularweb.org/patients/NorthPoint/Tho
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Signs Symptoms

• Tearing or ripping chest pain radiating to back
• Neuro symptoms syncope, coma, convulsions,
  hemiplegia
• Hoarseness
• Stridor
• Dysphagia
• Absent or diminished pulses

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Diagnosis

• CXR
• widened mediastinum
• Abnormal aortic contour
• Contrast CT
• MRI/MRA
• Angiography
• TEE
• TTE

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Thoracic Aortic Aneurysms
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Treatment

• DeBakey II medical management, control
  hypertension with nitroprusside or labetalol
• Surgery for ruptured aneurysms

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Total Artificial Heart
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