Surgery Exam 2 Review
Cardiac Surgery
CABG for CAD
• #1 cause of death in BOTH men and women in the US
• RF → genetics, HTN, DM, age, cholesterol, smoking, Fhx, obesity
• GOLD STANDARD → ANGIOGRAM
• Who goes to the OR?
o Triple vessel disease, Left main disease, failed medical therapy, thrombosis, post PTCA, emergently from
cath lab (coronary dissection), other open heart procedures (valve operation)
• CABG
o Aims to restore flow from aorta to coronaries distal to obstruction
o ON pump vs OFF pump (off pump does not need heart & lung machine)
▪ Off pump MAY decrease risk of complications but surgeon skill set required
▪ Do it in →
• Those >70, renal disease, CAD or those with risk of stroke, pulmonary disease
o Cardiopulmonary bypass STILL STANDARD
▪ Bloodless, quiet, operative field
▪ Heart & lungs are stopped while systemic circulation continues via heart-lung machine
o CONDUIT CHOICES for BYPASS
▪ Gold standard to use the LIMA
▪ Saphenous vein graft → good supply, 2 legs worth, less/no infection with endoscopic vessel
harvesting
▪ Radial artery → patency, less infections, early ambulation
o Post of complications of CABG
▪ A fib, vent dependency/resp failure, stroke (clots), pericardial tamponade, sternal wound
infection, post op MI/acute graft closure
,Aortic Valve
• Stenosis from thickening/calcifications and causes LV outflow obstruction
• Seen in younger patients with congenital bicuspid valves & older pt with hx of rheumatic fever
• S&S → angina, syncope, CHF (worse if not treated)
o Systolic murmur (crescendo-decrescendo) at 2nd right intercostal space
• Dx → ECHO +/- cardiac cath
• Tx → surgery is symptomatic
SYSTOLIC MURMURS → AS MI TIPS
AORTIC STENOSIS
• L ventricle hypertrophy due to pressure causing thickening
• Can lead to diastolic dysfunction
• Ventricles dilate and leads to increased pulm pressure and CHF
• Can get SEVERE hypotension on exertion
• Tx →
o Meds → digoxin & diuretics for CHF
o BE VERY CAREFUL WITH MEDS THAT LOWER PERIPHERAL VASC RESISTANCE (BB/NITRATES)
▪ ACE contraindicated if severe
o Balloon valvuloplasty (temporary relief)
o Aortic valve replacement → Tissue, mechanical or pulmonary autograft (ross procedure)
AORTIC INSUFFICIENCY
• Incompetence of aortic valve
• Causes: bacterial endocarditis, hx rheumatic fever, aortic root dilatation, bicuspid valve predisposes, Marfans
• ON PE → blowing (decrescendo) diastolic murmur at L sternal border
o High systolic, low diastolic pressure and widened pulse pressure
o Eventually leads to LV dysfunction and CHF
• Dx → echo, cath
• Tx → surgery if symptomatic with severe AI, acute w/ HF, impaired LV function, bacteremia, annular abscess
o Valve replacement BEFORE LV end-systolic dimension exceeds 55 mmHg and EF falls below 55%
o Medical therapy if surgery is not possible
▪ Afterload reduction → ACE INHIBITOR, BB, DIURETICS
, MITRAL STENOSIS
• Thickening of mitral leaflets making the valve narrow (ALMOST ALWAYS DUE TO RHEUMATIC FEVER)
• S&S → dyspnea from LA pressures causing pulmonary edema, a-fib from dilated LA
o Decreased preload reduces cardiac output
o Untreated leads to CHF but normal LV function
• Dx → echo/cath
o PE → diastolic murmur at apex. Opening snap
• Tx → surgery depends on sx/degree of MS (NO BALLOON VALVULOPLASTY)
o Open commissurotomy is the surgical tx BUT if too calcified/fused then VALVE REPLACEMENT
MITRAL REGURGITATION
• Incompetence valve from mitral prolapse, rheumatic fever, papillary muscle dysfunction (post MI), ruptured
chordae, dilations of annulus
• S&S → dyspnea, palpitations, fatigue, late onset
o Preload increased & afterload initially decreased
o Increases LA pressure (leads to LAH and a-fib)
o Eventually systolic function deteriorates
• Dx → echo/cath
o On PE → holosystolic murmur from apex to axilla
• Tx → surgical for degenerative MR, dilated annulus, flail leaflet or ring annuloplasty
o Otherwise mitral replacement (for mechanical INR must be 2.5-3.5)
Mitral Valve Prolapse
• Myxomatous or “floppy” mitral valve (10% of women have this)
o Can also be in those with Marfan, ehlers-danlos syndrome, osteogenesis imperfecta
• Can develop significant mitral regurg
• HALLMARK → MID SYSTOLIC CLICKS
• S&S → chest pain, dyspnea, light headedness, fatigue, palpitations, arrythmias
• Tx → BETA BLOCKERS (for palpitations)
o Surgical → mitral valve repair FAVORED over replacement
▪ Small incision robotic procedure
Cardiac Surgery
CABG for CAD
• #1 cause of death in BOTH men and women in the US
• RF → genetics, HTN, DM, age, cholesterol, smoking, Fhx, obesity
• GOLD STANDARD → ANGIOGRAM
• Who goes to the OR?
o Triple vessel disease, Left main disease, failed medical therapy, thrombosis, post PTCA, emergently from
cath lab (coronary dissection), other open heart procedures (valve operation)
• CABG
o Aims to restore flow from aorta to coronaries distal to obstruction
o ON pump vs OFF pump (off pump does not need heart & lung machine)
▪ Off pump MAY decrease risk of complications but surgeon skill set required
▪ Do it in →
• Those >70, renal disease, CAD or those with risk of stroke, pulmonary disease
o Cardiopulmonary bypass STILL STANDARD
▪ Bloodless, quiet, operative field
▪ Heart & lungs are stopped while systemic circulation continues via heart-lung machine
o CONDUIT CHOICES for BYPASS
▪ Gold standard to use the LIMA
▪ Saphenous vein graft → good supply, 2 legs worth, less/no infection with endoscopic vessel
harvesting
▪ Radial artery → patency, less infections, early ambulation
o Post of complications of CABG
▪ A fib, vent dependency/resp failure, stroke (clots), pericardial tamponade, sternal wound
infection, post op MI/acute graft closure
,Aortic Valve
• Stenosis from thickening/calcifications and causes LV outflow obstruction
• Seen in younger patients with congenital bicuspid valves & older pt with hx of rheumatic fever
• S&S → angina, syncope, CHF (worse if not treated)
o Systolic murmur (crescendo-decrescendo) at 2nd right intercostal space
• Dx → ECHO +/- cardiac cath
• Tx → surgery is symptomatic
SYSTOLIC MURMURS → AS MI TIPS
AORTIC STENOSIS
• L ventricle hypertrophy due to pressure causing thickening
• Can lead to diastolic dysfunction
• Ventricles dilate and leads to increased pulm pressure and CHF
• Can get SEVERE hypotension on exertion
• Tx →
o Meds → digoxin & diuretics for CHF
o BE VERY CAREFUL WITH MEDS THAT LOWER PERIPHERAL VASC RESISTANCE (BB/NITRATES)
▪ ACE contraindicated if severe
o Balloon valvuloplasty (temporary relief)
o Aortic valve replacement → Tissue, mechanical or pulmonary autograft (ross procedure)
AORTIC INSUFFICIENCY
• Incompetence of aortic valve
• Causes: bacterial endocarditis, hx rheumatic fever, aortic root dilatation, bicuspid valve predisposes, Marfans
• ON PE → blowing (decrescendo) diastolic murmur at L sternal border
o High systolic, low diastolic pressure and widened pulse pressure
o Eventually leads to LV dysfunction and CHF
• Dx → echo, cath
• Tx → surgery if symptomatic with severe AI, acute w/ HF, impaired LV function, bacteremia, annular abscess
o Valve replacement BEFORE LV end-systolic dimension exceeds 55 mmHg and EF falls below 55%
o Medical therapy if surgery is not possible
▪ Afterload reduction → ACE INHIBITOR, BB, DIURETICS
, MITRAL STENOSIS
• Thickening of mitral leaflets making the valve narrow (ALMOST ALWAYS DUE TO RHEUMATIC FEVER)
• S&S → dyspnea from LA pressures causing pulmonary edema, a-fib from dilated LA
o Decreased preload reduces cardiac output
o Untreated leads to CHF but normal LV function
• Dx → echo/cath
o PE → diastolic murmur at apex. Opening snap
• Tx → surgery depends on sx/degree of MS (NO BALLOON VALVULOPLASTY)
o Open commissurotomy is the surgical tx BUT if too calcified/fused then VALVE REPLACEMENT
MITRAL REGURGITATION
• Incompetence valve from mitral prolapse, rheumatic fever, papillary muscle dysfunction (post MI), ruptured
chordae, dilations of annulus
• S&S → dyspnea, palpitations, fatigue, late onset
o Preload increased & afterload initially decreased
o Increases LA pressure (leads to LAH and a-fib)
o Eventually systolic function deteriorates
• Dx → echo/cath
o On PE → holosystolic murmur from apex to axilla
• Tx → surgical for degenerative MR, dilated annulus, flail leaflet or ring annuloplasty
o Otherwise mitral replacement (for mechanical INR must be 2.5-3.5)
Mitral Valve Prolapse
• Myxomatous or “floppy” mitral valve (10% of women have this)
o Can also be in those with Marfan, ehlers-danlos syndrome, osteogenesis imperfecta
• Can develop significant mitral regurg
• HALLMARK → MID SYSTOLIC CLICKS
• S&S → chest pain, dyspnea, light headedness, fatigue, palpitations, arrythmias
• Tx → BETA BLOCKERS (for palpitations)
o Surgical → mitral valve repair FAVORED over replacement
▪ Small incision robotic procedure
