Cardiothoracic Surgery
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| What are some anatomical landmarks in cardiothoracic surgery? | In deep inhalation spleen and liver become in chest so they may be injured Posterior to the lung is 12th rib Arteries and nerves intercostal are in the lower part of ribs (important for chest tube placement) Thoracic outlet (subclavian arteries and veins) give mammary artery |
| What are main causes of chest trauma? | • Penetrating Trauma: - Projectile that enters chest causing small or large hole (bullet, explosive shell). - Stab wounds to the chest. - High velocity accidents (sharp glass, etc.). • Blunt Trauma: - Blunt force to the chest without open injury |
| What are blunt thoracic trauma? | Contusion (lung bleed) Pneumothorax • Heart block or ischemic changes. • Sustained or multifocal ventricular contractions. • Septal rupture. • Pulmonary or tricuspid valve incompetence. • Aortic or mitral valve incompetence. • Papillary muscle dysfunction • Distal coronary artery occlusion. • Proximal coronary artery occlusion. • Pericardial laceration with cardiac herniation. • Injury of the right ventricle, right or left atrium. • Left ventricular perforation. • Avulsion of the heart Tricuspid Valve Rupture (Flail septal leaflet w/deviated regurgitation) |
| What are open thoracic trauma? | • Open Pneumothorax, Tension Pneumothorax. • Flail Chest. • Hemothorax. • Hemopericardium, Cardiac Tamponade. • Cardiac injuries. • Traumatic Aortic Injury or Rupture. • Diaphragmatic Rupture. |
| How is open pneumothorax? | • Opening in chest cavity that allows air to enter pleural cavity. • Causes the lung to collapse due to increased pressure in pleural cavity. • Can be life threatening and can deteriorate rapidly. S&S (• Dyspnea. Sudden sharp pain. Subcutaneous Emphysema (means nothing) Decreased lung sounds on affected side. Red Bubbles on Exhalation from wound (Sucking chest wound). tx: • High Flow oxygen. • Apply occlusive dressing to wound. • Transport to a hospital setting and chest tube insertion |
| What is tension pneumothorax? | • Air builds in pleural space with no where for the air to escape. • Results in collapse of lung on affected side that results in: - pressure on mediastium and heart cavities, - pressure on the other lung, - pressure on great vessels S&S (tachypnea, tachycardia, poor color, jugular vein distention, hypotension, dyspnea, anxiety, abscent breath sounds, acessory muscle use) Tx (Needle decompression [2-3 intercostal space midclavicular, cleanse, insert cath over 3rd rib 14g, remove stylette and listen to air rush |
| What is flail chest? | - At least double fractures per rib. - At least three consecutive fractured ribs S&S (SoB, paradoxical movement IMP, bruising/swelling, Crepitus) True emergency Tx: Before hospital: • Use Trauma bandage and Triangular Bandages to splint ribs. • Can also place a bag of D5W on area and tape down. Osteosynthesis Judet's Staples (staple ribs together)/ Borelly's/STRATOS staples |
| What is hemothorax? | • Occurs when pleural space fills with blood. • Usually occurs due to lacerated intercostal or pulmonary vessel in the thorax. • As blood increases, it puts pressure on heart and other vessels in chest cavity S&S (IMP flat neck veins, anxiety, tachypnea, signs of shock, bloody sputum, diminished breath sounds, tachycardia) Tx (General shock care due to blood loss and monitoring heart rhythm, two large bore IV and draw blood samples, airway management (intubation), chest tube if needed (if hemodyamically unstable) |
| What are acute indications for thoracotomy? | • Acute deterioration and hemodynamic instability (blood pressure < 80 mm Hg). • Initial chest tube output of 1,500 mL of blood. • Continued bleeding of >200 mL/h. • Traumatic thoracotomy. • Massive air leak. • Documented tracheal or bronchial injury. • Suspected air embolism |
| What is difference between low velocity and high velocity chest injury? | Low velocity (contusion) high velocity (local injury) |
| What is Hemopericardium Cardiac Tamponade? | • Distended Neck Veins. • Tachycardia. • Polypnea. • Poor skin color. • Narrowing Pulse Pressures. • Hypotension. • Death. Tx: • High Flow oxygen. • Cardiac Monitor. • Large Bore two IV accesses. • Pericardiocentesis. • Pericardial surgical drainage (pericardial window) |
| What are S&S of cardiac injuries?TX? | • Distended Neck Veins. • Tachycardia. • Polypnea. • Poor skin color. • Narrowing Pulse Pressures. • Hypotension. • Death Tx: • High Flow oxygen. • Cardiac Monitor. • Large Bore two IV accesses or a Central Catheter. • Sternotomy. • Surgical repair |
| What is traumatic aortic injury? | Burning or Tearing Sensation in chest or shoulder blades. • Rapidly dropping Blood Pressure. • Pulse Rapidly Increasing. • Decreased or loss of pulse or b/p on left side compared to right side. • Rapid Loss of Consciousness If we get traumatic aortic rupture: Rapidly dropping Blood Pressure. Rapid Loss of Consciousness. Death |
| How is tx of traumatic aortic injuries? | • High Flow oxygen. • Treatment for Shock. • Monitor Cardiac Rhythm. • Large Bore two IV accesses and draw blood samples. • Airway management that may include Intubation. • Surgical repair IMP/ Endovascular repair |
| What is diaphragmatic rupture? | • A tear in the Diaphragm that allows the abdominal organs enter the chest cavity. • More common on Left side due to liver helps protect the right side of diaphragm. • Associated with multiple injury patients S&S (• Abdominal Pain. • Shortness of Air. • Decreased Breath Sounds on side of rupture. • Bowel Sounds heard in chest cavity (IMP)) |
| What is tx of diaphragmatic rupture? | • High Flow oxygen. • Treat Associated Injuries. • Observe for compression on lung by abdominal contents. • Possible insertion of NG tube to help decompress the stomach and relieve pressure. • Consider urgent surgical repair IMP |
| What is most imp benign pleural tumors? | • Benign fibrous tumors. |
| What is most frequent malignant pleural tumors? | Mesothelioma. (most common), Malignant fibrous tumors. |
| How is tx of fibrous tumors of pleura? | • Wide local excision, including pulmonary and pleural resections (lobectomy, pneumonectomy, etc…). • Resection of a lesion arising from the parietal pleura should include the tissue down to the endothoracic fascia. • If resection is complete, no indication for adjuvant therapy (radiation therapy, chemotherapy) |
| What is mesothelioma? | Different from benign asbestos plaques (more continuous) • Mean survival: < 1 year. • Main etiology: asbestos exposure (amiante). • Male predominance. • Long latent period (starting of exposure until disease: >20 years). • Age of appearance: between 50 and 70. • Incidence: 10 per million inhabitant per year. Main cause is asbestors, other non asbestos causes: radiation, organic chemicals, chronic inflammation [TB, recurrent diverticulitis, FMF], non specific industrial exposure (shoe industry, petrochemistry, stone cutter, leather factory, Copper, nickle, hereditary predisposition) |
| What are histologic classifications of mesothelioma? | • Epithelial ( Tubulopapillary, Epithelioid IMP, Glandular, Large cell (giant cell), Small cell, Adenoid-cystic ,Signet ring) • Sarcomatoid (fibrous, sarcomatous, mesenchymal) • Mixed epithelial-sarcomatoid (biphasic) • Transitional • Desmoplastic • Localized fibrous mesothelioma |
| How is clinical presentation of mesothelioma? | • Early stages: dyspnea (pleural effusion). • Continuous chest discomfort. • Advanced stage: - excruciating chest pain (tumor infiltration of the chest wall and intercostal nerves). - sense of chest tightness and dyspnea caused by entrapment of the lung by tumor. - severe and unremitting dyspnea and chest pain Uncommon sx (cough, weakness, anorexia, fever, hemoptysis, hoaseness, dysphagia, horner's) |
| How is dx of mesothelioma? | • Pleural fluid cytology (positive in 30-50%). • Pleural biopsy (videothoracoscopic surgery). • Open surgical pleural biopsy. • CT scan of the chest and abdomen, and PET scan (diagnose and stage patients). • Bronchoscopy (exclude a primary lung cancer with endobronchial tumor). |
| How is staging of mesothelioma? | • Stage I: Tumor confined within the the parietal pleura, i.e., involving only ipsilateral pleura, lung, pericardium, and diaphragm. • Stage II: Tumor invading chest wall or involving mediastinal structures, e.g., esophagus, heart, opposite pleura Lymph node involvement within the chest. • Stage III:Tumor penetrating diaphragm to involve peritoneum; involvement of opposite pleura Lymph node involvement outside the chest. • Stage IV: Distant blood-borne metastases |
| How is tx of mesothelioma? | • Surgery. IMP • Radiation therapy. • Chemotherapy. • Immunotherapy. • Supportive care |
| What is mesothelioma surgery? | • Extrapleural pneumonectomy: en bloc resection of the pleura, lung, ipsilateral hemidiaphragm, and pericardium. • Pleurectomy-decortication: remove all gross pleural disease without removing the underlying lung, the hemidiaphragm and pericardium are also removed. • Palliative pleurectomy: limited resection of the parietal pleura to control a pleural effusion by creating a durable pleurodesis. |
| How is right extrapleural pneumonectomy? | Right extrapleural pneumonectomy (Thoracotomy: 5th intercostal space, Extra-pleural anterior dissection, Extra-pleural posterior dissection, Diaphragmatic excision, Pericardial excision, Controlling hilum and stapling its vascular and bronchial components, Diaphragmatic and Pericardial replacement prostheses) |
| What are results of mesothelioma surgery? | • Operative mortality (according to the center’s experience): 3-30%. • Two- and five-year survival rates are aproximately 40% and 15%, respectively Recurrent disease, metastasis |
| What are things to be aware of in thoracic sympathectomy? | - Horner’s syndrome (ptosis, myosis, enophtalmy, and palpebral anhydrosis), - Reactive hyperhydrosis of the lower body, - Dry skin of the upper body |
| What are important anatomic landmarks and surgical techniques for thoracoscopic surgery? | Intercostal arteries come from descending aorta. • Classical thoracotomy techniques (5th intercostal space incision), big and multiple retractors used: - invasive, - trauma to chest wall muscles, - trauma to intercostal nerves with longterm consequences (chest wall paresthesia) due to retractors and closure stitches, - chronic pleuritic pain (weather changes). • Minimally invasive video-assisted techniques (VATS) avoid most of these side effects. |
| What are advantages of VATS? | • Less invasive. • Less traumatic to chest wall muscles and intercostal nerves. • Less pleuritic pain. • Less pulmonary post-operative complications. • Less cardiac post-operative complications. • Faster recovery. • Less hospital stay |
| What are thoracoscopic surgery general principles? | • General anesthesia. • Oro-tracheal selective intubation: double-lumen tube (Carlens, Malinckrodt®) Instruments: Trocars Patient Positioning (triportal trocar positioning) |
| What are indications of VATS? | • Diagnostic pleuroscopy. • Pleural biopsies. • Lung biopsies. • Mediastinal biopsies. • Resection of pleural adhesions: (empyema, hemothorax, chronic effusion) • Pleurectomy (recurrent pneumothorax.) • Pleurodesis: (pleural carcinosis, recurrent benign pleural effusion) • Pericardial effusion (pericardial biopsy, pericardiocenthesis (posterior loculations), creation of a pleuro-pericardial window (drainage of benign pericardial effusion into the pleura). • Bullae resection: (emphysema (obstructive disease), bullous disease of the pulmonary apex (blebs)) • Pulmonary resections: nodule, wedge, lobectomy, pneumonectomy) |
| What is indication for VATS thoracic sympathectomy? | - Hyperhidrosis of the hands, - Erythrophobia (increased reactivness of the face: excessive redness), - Raynaud’s disease (isolated), - Ischemic disease of digits. |
| What are indications of VATS in sponteneous pneumothorax bleb rupture? | - Persistent air leak after adequate drainage, - Recurrent pneumothorax (1st episode), - Bilateral pneumothorax, - First episode of pneumothorax, for socioprofessional obligations (divers, pilots, etc…). use apical bullectomy, mechanical pleurodesis, pleurectomy |
| What is important indicator in pleural effusion? | Pleural protein/ serum protein (if >0.5: exudative effusion) LDH pleural/ LDH serum (if >0.6 : exudative effusion) |
| How is mediastinal lymph node biopsies using VATS? | Anterior mediastinum reach periaortic lymph nodes through 2nd intercostal space, mediastinal lymph nodes reach by midaxillary incision |
| What are indications of Lobectomy VATS? | • Clinical stage I lung cancer. • Tumor size < 5 cm. • Benign disease (e.g., giant bulla, bronchiectasis). • Physiologic operability |
| What are CI for VATS lobectomy? | • Chest wall or mediastinal invasion (T3 or T4 tumor). • Endobronchial tumor seen at bronchoscopy. • Positive mediastinoscopy. • Neoadjuvant chemotherapy. • Neoadjuvant radiation therapy. |
| What are things to be aware of in thoracic sympathectomy? | - Horner’s syndrome (ptosis, myosis, enophtalmy, and palpebral anhydrosis), - Reactive hyperhydrosis of the lower body, - Dry skin of the upper body |
| What are main mediastinal considerations in mediastinoscopy? | Ant; lymphoma and gioter, middle lymphoma |
| What are indications for mediastinoscopy? | • Staging of lung cancer: - suspicion of N3 (contra-indication to resection), - search for N2 (induction chemotherapy before resection), - suspicion of small cell lung carcinoma(contra-indication for surgery). • Typing of tumors: - lung cancer: if bronchoscopy is non contributive, - mediastinal tumors: histological typing (lymphoma, thyroid goiter or neoplasm, etc). • Diagnosis of inflammatory diseases: sarcoidosis (biopsy of mediastinal lymph nodes) |
| What are complications of mediastinoscopy? | • Hemorrhage (innominate vein or aorta). • Tracheal or bronchial lacerations. • Esophageal lacerations. • Recurrent nerve lesion (sectioned or electrocoagulated). • Pneumothorax. • Skin infection |
| What are solitary lung nodules? | • “Coin lesion”: - Defined as < 3 cm. - Completely surrounded by lung parenchyma. • Lesions > 3 cm called “masses” and often malignant • Risk Factors: - Smoking: • Lung cancer is 10 times more common in smokers compared to non-smokers. - History of lung cancer in a first degree relative. - Exposure to asbestos, uranium and radon. - Rare in under 35 years of age • Incidence of cancer from 10 – 70%. • 90% incidental findings. • Increased with incidental findings on CT. • Patients with best prognosis are stage IA (T1N0M0) |
| What are radiologic margins of lung nodules? | • Corona radiata sign. Fine linear strands extending 4-5 mm outward. 84 – 90% are malignant) • Scalloped border (Intermediate probability of cancer. Smooth border suggestive of benign diagnosis) Air bronchogram sign of malignancy Calcification sign of benign disease Popcorn calcification sign of hamartoma Eccentric calcification (might be malignant) |
| What are imagings used? | PET scan, CT guided biopsy |
| How is incidence of lung cancer? | An estimated 2 million new cases of lung cancer are expected globally in 2020, 84% NSCLC • Cancer is the second leading cause of death globally. • 1 in 6 deaths is due to cancer. • Approximately 70% of deaths from cancer occur in low- and middle-income countries. • Tobacco use is responsible for approximately 22% of cancer deaths. • The total annual economic cost of cancer in 2010 was estimated at approximately US$ 1.16 trillion. It is the most frequent cancer WW, has highest mortality |
| What are sx of lung cancer? Casue? Prevention? | Most are asx 10% sx (cough, hemoptysis, SoB, weight loss, clubbing) Major cause: smoking, others (radiation, pollution, asbestos) Best prevention stop smoking, second best screening by low dose CT Imaging enables visualisation of the size and location of tumours, and potential nodal involvement Chest X-ray is often used first due to its widespread availability More detailed imaging of lymph nodes, soft tissues and tumours is performed through MRI and/or PET/CT scans due to their increased sensitivity Low dose radiation CT scanners induce 20% reduction in lung cancer mortality |
| What are dx procedures of lung cancer? | • Flexible bronchoscopy (and biopsy). • EBUS. • CT guided biopsy. • Surgical lung biopsy (Thoracotomy side 5th intercostal space/ thoracoscopy, exisional biopsy of nodes, nodule resection excisional biopsy, Uniportal VATS) • Directly to surgery (resection GOLD STD, lobectomy or pneuomonectomy (used normal), wedge/segmentectomy (abnormal use) |
| What are main mediastinal tumors? | Thymoma (invasive or not), Lymphoma: Hodgkin, Cystic hygroma: lymphangioma Mediastinal goiter, Teratoma (mature), Germinal tumor, Epithelioid haemangioendothelioma, Sarcoidosis: hilar lymph node, Schwannoma, Neurogenic tumors. IMPORTANT mediastinum is best seen by CT |
| What are thymic tumors in epithelium? | • Benign Encapsulated thymoma • Malignant Invasive thymoma Epithelial Lymphocytic Mixed lymphocytic and epithelial • Thymic carcinoma Squamous cell carcinoma Lymphoepithelioma-like carcinoma Basaloid carcinoma Mucoepidermoid carcinoma Sarcomatoid carcinoma Mixed small cell/undifferentiated/squamous cell carcinoma |
| What are histologic classifications of thymomas? | • Type A thymoma (medullary) - benign • Type AB thymoma (mixed) - bening • Type B thymoma: Type B1 (organoid) Type B2 (cortical) Type B3 (epithelial) - malignant • Type C (thymic carcinoma) - malignant |
| Clinical Disorders Associated with Thymomas | Myasthenia gravis (dx by anti Ach Ab) we have neuromuscular syndromes, Hematologic syndromes, Collagen diseases, dermatologic, endocrine, renal, bone, malignancy |
| What are germ cell tumors of thymus? | • Seminoma • Teratoma: Benign cystic teratoma Immature teratoma Malignant teratoma • Embryonal carcinoma • Endodermal sinus tumor (yolk sack tumor) • Choriocarcinoma • Combined germ cell tumors |
| What are other types of thymic tumors? | • Tumors of lymphoid origin: Malignant lymphoma Hodgkin's disease Non-Hodgkin's lymphomas (lymphoblastic, others) • Tumors of neuroendocrine cell origin: Carcinoid Oat cell carcinoma • Tumors of adipose tissue: Thymolipoma • Metastatic tumors of the thymus |
| What is indication for mediastinoscopy? | • Typing of tumors: - mediastinal tumors if accessible for histological typing (thymoma, lymphoma, thyroid goiter or neoplasm, etc). - lung cancer: if bronchoscopy is non contributive, • Diagnosis of inflammatory diseases: - sarcoidosis (biopsy of mediastinal lymph nodes) |
| What are complications of mediastinoscopy? | • Hemorrhage (innominate vein or aorta). • Tracheal or bronchial lacerations. • Esophageal lacerations. • Recurrent nerve lesion (sectioned or electrocoagulated). • Pneumothorax. • Skin infection. |
| What are thoracoscopic surgeries done in mediastinal diseases? | Resection of thymomas, Neurogenic tumors, Mini-Sternotomy: Goiter, Sternotomy: Melanoma |
| What are mediastinal infections? | Tuberculosis, Mediastinitis |
| What are congential pathologies of heart? | Atrial septal defect (sinus venosus, secundum, caval) Causes more flow to pulmonary artery than aorta, most common is secundum Ventricular septal defect Pulmonary Atresia (pulmonary artery closed early) Aortic stenosis Teratology of fallot (VSD, atresia, aortic valve disposition and ASD, might cause cyanosis called cynaotic congential heart defect) Transposition of great vessels (not viable, 2alabo l large veessles, to live should have patent duct) Patent Ductus arteriosus |
| What are acquired heart diseases? | CAD (atherosclerosis, infarction) Valvular diseases (aortic stenosis (most common, types [rheumatic cause stenosis and regurg, calcific pure stenosis, bicuspid may be normal]) Aortic regurgitation [valve not closed completely] Bicuspid valve, mitral stenosis, mitral regurgitation, tricuspid regurgitation) Cardiomyopathy (dilated or hypertrophic [can be primary or acquired aortic stenosis]) Electrical block Pericardial effusion |
| What are closed heart operations? | Ligation of Patent Ductus Arteriosus (midaxillary incision) Off-pump coronary artery bypass Pace maker implantation (Skin incision, Sub-clavian vein puncture, Lead(s) introduction using Seldinger technique., Operative theater using a C-arm with Xray.) Pericardiocentesis Surgical drainage Pericardial window |
| What is cardiopulmonary bypass (Heart-lung machine)? | O2 poor blood leaves heart enters the machine, pumped added O2 blood to heart, goes to organs but skips heart and lungs |
| What are open heart operations? | Closure of ASD, VSD (patches) Repair of pulmonary atresia, teratology of fallot (patch to enlarge pulmonary valve and RV outflow), transposition of great vessels |
| What is coronary artery bypass grafting (CABG)? | We take a part mostly of internal mammary artery (easy access) and less from gastro-epiploic artery (GEA) and rarely radial artery. We may take greater and lesser saphenous vein grafts Do coronary anastomosis, so we get arterial CABG We may also do venous CABG (in case we do 4 CABGs) Atypical CABGs (LIMA-LAD, LIMA-Dg-LAD, SV-Mg) |
| What are valve replacements? | Two types Biological and mechanical Biological (stentless or stented [porcine/pericardial valve]) Mechanical (tilting disc or bileaflet) We may have aortic valve replacement, aortic valve repair [if floppy valve leaflet], mitral valve replacement or repair, tricuspid valve repair |
| How are interventions of myocardial HF? | Intra-Aortic Balloon Pump, ECMO, LVAD: Centrifugal pump, BiVAD: Totally implantable heart If no recovery: Go for Heart Transplant (Donor heart harvesting, Recipient heart explantation, Suturing LA, vena cava and great vessels |
| How is aortic anatomy? | Ascending thoracic aorta, aortic arch, descending thoracic aorta, abdominal aorta Stress of aorta: • The aorta has continuous exposure to high pulsatile pressure and shear stress. • The aorta is more prone to rupture than any other vessel especially with the development of aneurysmal dilatation. Types of aneurysms: • True aneurysm - Saccular - Fusiform • False aneurysm or pseudoaneurym |
| How are types of aneurysms? | • True aneurysm involves all three layers of the vessel. - A fusiform aneurysm affects the entire circumference of segment of the vessel resulting in a diffusely dilated lesion. - A saccular aneurysm involves only a portion of the circumference resulting in an outpouching of the vessel wall. • False aneurysms involve the inner layers of the aorta. It is a partial rupture of the aorta, contained by the adventitia |
| How is etiology of fusiform aortic aneurysms? | • The most common pathologic condition associated with aortic aneurysm is Atherosclerosis. • Cystic medial necrosis is the degeneration of collagen and elastic fibers in the tunica media of the aorta. • It affects the proximal part of the aorta causing a fusiform aneurysm. • The fusiform aneurysm is particularly prevalent in patients with: (Marfan’s syndrome. Pregnant women. Hypertensive patients., Valvular heart disease patients. ) • Syphyllis is an uncommon cause of aortic aneurysm. • Tuberculous and mycotic aneurysms are rare conditions. • Vasculitis. • Spondyloarthropathies. • Traumatic. • Congenital aortic anuerysms (usually associated with bicuspid aortic valve or aortic coartation). |
| How are thoracic aortic aneurysms? | Thoracic aortic aneurysms (• The average growth of the aneurysm is 0.1 to 0.4 cm/year. The risk of rupture is related to the size of the aneurysm especially when > 55 mm in diameter for the ascending aorta and > 60 mm for the descending aorta • Most often is asymptomatic. • Compression or erosion of adjacent tissue may cause chest pain, dyspnea, cough, hoarseness, dysphagia. • Congestion of head, neck and upper extremities secondary to compression of the superior vena cava. • Dilated aortic root with aortic valve regurgitation. • Congestive heart failure secondary to aortic regurgitation • Imaging includes: Chest X-ray (might show mediastinal enlargement). Echocardiogram: trans-thoracic, trans-esophageal, or both. CT angio-scanner (Gold Standard). Magnetic Resonance Imaging (MRI). |
| How are abdominal aortic aneurysms? | • It occurs in males more than females. • The incidence increases with age. • Atherosclerosis affects more than 90% of the aneurysms > 40 mm in diameter. • Most of them are below the renal arteries. • The 5 year risk of rupture for aneurysms < 50 mm is 1 to 2%. • The 5 year risk of rupture for aneurysm > 50 mm is 20 to 40%. • The formation of mural thrombi within the aneurysm may predispose to peripheral embolization. • AAA produces no symptoms and it is usually detected on routine examination as a palpable pulsatile and non tender mass. • It is usually an incidental finding during an abdominal CT scanner or ultrasound performed for other reasons. • If AAA expands, it may produce severe pain in the abdomen, or lower back due to mass effect. • Aneurysmal pain is an emergency because it is an early sign of rupture |
| What is aortic dissection? | • Blood violates aortic intimal and adventitial layers • False lumen is created • Dissection may extend proximally, distally, or in both directions Effects on aortic root Aortic valve and Coronary arteries flails Classifications: • DeBakey and co-workers classification - Type I: The intimal tear occurs in the ascending aorta but which involves the descending aorta as well. (60%) - Type II: The dissection is limited to the ascending aorta. (10-15%) - Type III: The tear is located in the descending thoracic aorta (25-30%) |
| What are etiologies of aortic dissection? | • Hypertension (known or misdiagnosed). • Connective tissue diseases: - Marfan syndrom. - Ehlers-Danlos syndrom. • Congenital malformations: - Bicuspid aortic valve. - Coarctation of the aorta • Traumatic (car accident: frontal shock). • Iatrogenic: - arterial catheterism. - during or after cardiac surgery. • Pregnancy (rare). |
| How is presentation of aortic dissection? | Typical: • Acute chest pain. • Abrupt onset. • Stabbing pain. • Irradiating pain to the back. • Migrating pain to the lower back. • Tearing sensation. • Hypertensive patient. Atypical: • Neurological deficit or syncope: complete or partial obstruction of carotid arteries. • Hypotension: cardiac tamponade or massive bleeding. • Shortness of breath: hemothorax • Acute limb ischemia, acute mesenteric ischemia, acute renal artery obstruction renal failure |
| How is PE of aortic dissction? DD? | • Examine 4 limbs: - Asymetric pulses (not always present). - Asymetric blood pressure values (not always present), > 20 mmHg if present. • Heart auscultation: Diastolic aortic murmur due to aortic valve regurgitation (not always present) DD: • Myocardial infarction: - perform ECG and cardiac enzymes. • Cerebro-vascular accident: - perform carotid ultrasound and/or brain angio-scanner. • Pulmonary embolism: - perform a chest angio-scanner. • Pericarditis or Pericardial effusion and tamponade: - perform a cardiac ultrasound and/or a chest angio-scanner |
| How is management of aortic aneurysms? | • Blood pressure Control: - measure BP in 4 limbs and consider the highest. - if high, administer IV anti-hypertensive drugs (Loxen, Isoket, Ebrantyl, etc…). - if low, administer IV fluids. • Pain Control: - administer IV morphine, to lower pain, and secondarily to lower BP Imaging (CXR [if stable pt, see wide mediastinum sometimes], Angioscanner of thorax, abdopelvis, cardiac US if stable pt to see intimal flap/ AR/ pericardial effusion/tamponade, MRI can be performed but time consuming, arteriography not to be done when doubtful dx due to risk of rupture |
| How is management after dx? | Type A (• Call the Open Heart team for an emergent surgery. • Mortality increases by 2% each hour for total mortality rate of 95% Restore normal anatomy of aortic root, commissural resuspension and glueing of dissecton layers, aortic valve reimplantation [David Operation]) |
| What is intra-aortic balloon pump? | Balloon that controls coronary artery perfusion in case of heart failure, inflates to stop flow and deflates to continue Effects: lower LV afterload, enhances coronary perfusion during diastole. Indications: acute coronary syndrome, unstable angina, early stage heart failure CI: severe aortic valvular insufficiency, aortic dissection |
| What is extra-corporeal membrane oxygenation? | Modification of heart-lung machine, ECMO for respiratory failure, ECLS for heart failure. Drains venous blood, parallel circulation [mechanical pump] gas exchange in oxygenator, blood returns into artery/vein Indication: Acute ischemic HF, acute HF after open heart surgery, acute or chronic graft failure after heart transplant, pulmonary embolism, acute viral myocarditis w/HF, intoxication, hypothermia, drowning Requirements: pump, console, disposables, tubes, canulae [arterial and venous] Can be central or peripheral (femoral arteries and veins) circulatory support |