Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Cardiac Surgery & Anatomy James Cartlidge Specialty Doctorin Cardiothoracic SurgeryThanksto our partners! LearningOutcomes Coronary Artery Disease • Anatomy • Describe the origins, courses & main branches of the left & right coronary arteries & discuss the • Explain the venous drainage of the hearttion • Recognise the coronary arteries on angiogram • Describe the function of the pericardium • Clinical • What is coronary artery disease • Describe the pathophysiology behind coronary artery disease • What are the main risk factorsfor coronary artery disease • Describe the clinical presentation • What are the appropriate investigations • What is the appropriate management • Describe the coronary artery bypass graft procedure LearningOutcomes ValvularDisease • Anatomy • Describethefunctionalpartsof theadultheart (internal& external) • Locatetheatrioventricular,pulmonary&aortic valves on a heart,demonstratetheir surfacemarkings, & how theyrelatetoclinical & radiologicalexaminations,& describetheir rolein thepreventionof regurgitationof blood • Describewhere thevalves canbeauscultated • Described thepartsof theconductingsystemof theheart • Describetheanatomicalcourseof excitationthroughtheheart • Clinical • Whatis valvulardisease (stenosisvs. regurgitation) • Whatarethemain causes of valvular disease • Describetheclinical presentationof aortic stenosis/regurgitation&mitralstenosis/regurgitation • Describetheappropriateinvestigations • Discussmanagement options(catheter-basedoptions vs.open heartsurgery) • Describeopen heart surgery& discussvarious valvereplacement options The Coronary Arteries • Right Coronary • Sinoatrial nodal a. – supplies SAN (60%) • Right conus a. • Right marginal a. • dom - ~85%)nterventricular a. (R • LeftCoronary • Left main stem (LMS) • Left anterior descending a. (LAD) • Left conus a. • Left circumflex branch (LCx) • Left marginal a. • Sinoatrial nodal a. (40%) Gray’s Anatomy For Students, 4 Edition The Coronary Arteries • Sites of coronary artery occlusion, in order of frequency Orderof Frequencyof Occlusion CoronaryArtery 1 Proximalleft anteriordescendinga. 2 Proximalright coronarya. 3 Proximalleft circumflexbranch 4 Left mainstem 5 Proximalposteriorinterventriculara. 6 Right coronarya. (diaphragmaticsurface) Geeky Medics • Sites 1-3 account for up to 85% of all occlusions The Coronary Arteries • Ischaemic ECG lead changes corresponding to occluded coronary aa. InfarctedArea/ HeartView IschaemicChange – ECGLead CoronaryArtery Anteroseptal V1-V4 Left anteriordescendinga. Inferior II, III, aVF Right coronarya. (85%) Left mainstem (15%) Anterolateral V4-V6, I, aVL Left anteriordescendinga. or left circumflexbranch Anterior V3, V4 Distalleft anteriordescendinga. Lateral I, aVL, +/- V5-V6 Left circumflexbranch(I, aVL) Distalleft anteriordescendinga, left circumflexbranchorright coronary a. (V5-V6) Posterior TallR wavesV1-V2 Usuallyleft circumflexbranch,also right coronarya. Septal V1-V2 Proximalleft anteriordescendinga.The Coronary Arteries Geeky MedicsThe Coronary Arteries FirstAidfor the USMLE Step 1 2023 The Coronary Veins • Coronary sinus receive 4 major tributaries • Great cardiac v. • Middle cardiac v. • Small cardiac v. • Posteriorcardiac v. • Anterior cardiac vv. (RV) • Thebesian vv. (RA) Gray’s Anatomy For Students, 4 Edition The Coronary Veins • Coronary sinus receive 4 major tributaries • Great cardiac v. • Middle cardiac v. • Small cardiac v. • Posteriorcardiac v. • Anterior cardiac vv. (RV) • Thebesian vv. (RA) Gray’s Anatomy For Students, 4 EditionThe Coronary Vessels Gray’s Anatomy For Students, 4 EditionQuestion #1 A patient presents with symptoms of an acute coronary syndrome. ST elevation is present in leads V1-V2. Which coronary artery is occluded to produce these ischaemic changes? A. Left circumflex branch B. Right coronary a. C. Proximal left anterior descending a. D. Left anterior descending a. E. Distal left anterior descending a.Question #1 A patient presents with symptoms of an acute coronary syndrome. ST elevation is present in leads V3-V4. Which coronary artery is occluded to produce these ischaemic changes? A. Left circumflex branch B. Right coronary a. C. Proximal left anterior descending a. – Septal – most commonly occluded site D. Left anterior descending a. E. Distal left anterior descending a. CoronaryAngiography • Invasivecardiacinvestigation • a. anatomyue dye is injected through coronary ostia, todelineatecoronary • Aortic root accessgained through femoral, brachial, radial or ulnar aa. • Arterialsheath– percutaneous modified Seldinger technique • Coronary ostia engaged withvariety of preformed catheters • Judkins L or R • Differentviewsobtained described by position of X-ray detector • Right anterior oblique (RAO) – ribs descend toRHS of image, thoracic spine LHS of image • Left anterior oblique (LAO) – ribs descend to LHS of image, thoracic spine RHS of image • Cranial or caudal tilt CoronaryAngiography https://bjcardio.co.uk/2016/08/optimal-angiographic-views-for-invasive-coronary-angiography-a-guide-for-trainees/ CoronaryAngiography https://keck2.usc.edu/cardiovascular-medicine-division/wp-content/uploads/sites/140/2017/10/Basic-Coronary-Angiography_All-Slides.pdfCoronaryAngiography Key Questions inCardiacSurgeryCoronaryAngiography Key Questions inCardiacSurgeryCoronaryAngiography Key Questions inCardiacSurgery The Pericardium • 3 Layers (outer toinner) • Fibrous pericardium • Parietal pericardium • Epicardium (visceral pericardium) • Pericardialspace • Between parietal & visceral pericardium • Serous fluid • Prevents friction • Produced by epicardium • Innervated by phrenic n. • Referred pain FirstAidfor the USMLE Step 1 2023The Pericardium Gray’s Anatomy For Students, 4 EditionThe Pericardium Gray’s Anatomy For Students, 4 Edition CoronaryArtery Disease (CAD) • Narrowing (stenosis) or occlusion of the coronary arteries • Reduced blood flow to myocardium (ischaemic heart disease) • Reducing ability to match myocardial metabolic demand • Most common mechanism responsible is atherosclerosis • May present as • Angina pectoris • Acutecoronary syndrome • Worldwide leading cause of death • Substantial increase in prevalence, especially in high income countries CAD Pathophysiology • Stages of Development • Endothelial cell dysfunction • Macrophage & LDL accumulation • Foamcell formation • Linear fatty streakformation • Smoothmusclecell migration, proliferation & ECM deposition • Fibro-lipid plaque formation • Complexatheroma • Calcification (stiffening,stenosis) • Rupture(thrombus → distalischaemia) FirstAidfor the USMLE Step 1 2023CAD Pathophysiology FirstAidfor the USMLE Step 1 2023CAD Pathophysiology Key Questions inCardiacSurgery CAD Risk Factors UnmodifiableRiskFactors ModifiableRiskFactors • Increasingage • Smoking • Malegender • DiabetesMellitus • Familyhistory ofischaemic heart disease • Hypertension • Hypercholesterolaemia/hyperlipidaemia • Obesity • Alcoholconsumption • Low exercise / sedentarylifestyle • PoorSleep • Stress • Poordiet (high insugar& trans-fat;low in fruit, vegetables& omega-3s) PassMedicZero To Finals CAD Clinical Presentation Clinical Presentations • Angina Pectoris • Acute Coronary Syndrome • Unstableangina (UA) • Non-STelevation myocardial infarction(NSTEMI) • STelevation myocardial infarction(STEMI) • Heart Failure CAD Clinical Presentation Angina Pectoris Acute CoronarySyndrome • Chest pain • Chest pain • Central,heavy,gripping • Pressure, tightness, crushingsensation • Left side ofchest • Left side ofchest • Mayradiateto left arm or neck • Mayradiateto left arm or neck • Precipitatedby exertion • Occurs atrest • Relievedwith rest ofGTN • Maynot be present in elderlyordiabetics • Maynot be present in elderlyordiabetics • Dyspnoea • Dyspnoea • Mayoccurconcomitantlyorisolated • Minorityof patientmay present with • Nausea& vomiting • Nausea • Sweating • Light-headedness • Palpitations • Fatigue • Atypical • Epigastricpain • Fatigue • Syncopeor presyncope PassMedicTeach Me Surgery CAD Clinical Presentation AcuteCoronary Syndrome – On Examination • General Appearance • Anxious, restless, or profuse sweating – sympathetic activation • Cyanosis – hypoxia (severe cases) • VitalSigns • Blood pressure • Hypotension – cardiogenic shock • Hypertension – stress response • He• Tachycardia – canworsen ischaemia • Bradycardia – inferior MI due to vagal activation • Respiratory rate • Tachypnoea – heart failure,pain or anxiety • Oxygen saturation • Hypoxia – dependent on degree of cardiacdysfunction CAD Clinical Presentation • Canadian Cardiovascular Society classification • Functionalclassificationthatrelates patient’ssymptomsof angina with ability toperform activities CCSClassification Description I No limitationofphysicalactivity& no symptomswith ordinaryactivity II Slightlimitationofphysicalactivitywith anginaprecipitatedbyvigorousactivity III Marked limitationofphysicalactivitywith anginaprecipitatedbyroutineactivity IV Inabilityto perform anyactivitieswithout anginaorsymptomsof anginaat rest Key Questions inCardiacSurgery CAD Investigations • Coronary Angiography • Gold standardinvestigation for suspectedCAD • Interventional procedure • Contrast injected into coronary aa. • Serial CT images taken in sync with heartbeat • Identification of site(s) & degree of stenosisof coronary aa. • Influences managementplan • 75% stenosis– 50% loss of arterial diameter– angina with activity • 90% stenosis– 75-80% loss of arterial diameter– angina at rest • Echocardiography • Requestedfor potential CABG candidates • Provides measureof left ventricular ejectionfraction • Strong prognosticfactor in CABG TSRA Review of CardiothoracicSurgery CAD Investigations • Angina Pectoris Investigations • Forpatients in whom stableangina can’tbe excludedby clinical assessment alone, NICE recommendsthe following RecommendedInvestigationLine Investigation 1 Line CT coronaryangiography 2 Line Non-invasivefunctionalimaging(looking for reversiblemyocardialischaemia) 3 Line Invasivecoronaryangiography PassMedicine CAD Investigations • Acute Coronary Syndrome Investigations ACS TroponinI Level CK / CK-MB Level ECG InfarctLocation UnstableAngina Normal(<0.6 Normal TransientST None ng/mL) depression&/or T- waveinversionor normal NSTEMI Elevated(0.6-1.5 Elevated(<2x TransientST Subendocardial ng/mL) normal) depression&/or T- waveinversionor normal STEMI Elevated(>1.5 Elevated(>2x ST elevationorQ Transmural ng/mL) normal waves Key Questions inCaFirstAidfor the USMLE Step 1 2023CAD Investigations FirstAidfor the USMLE Step 1 2023Question #2 A patient presents with symptoms of angina. They find that they are limited in carrying out their activities of daily living, as they become breathless and experience chest pain when doing so. They have never experienced chest pain at rest. What CCS class does this patient belong to? A. I B. II C. III D. IVQuestion #2 A patient presents with symptoms of angina. They find that they are limited in carrying out their activities of daily living, as they become breathless and experience chest pain when doing so. They have never experienced chest pain at rest. What CCS class does this patient belong to? A. I B. II C. III - Marked limitation of physical activity with angina precipitated by routine activity D. IV CAD Management CAD • First line treatment for symptomatic relief of angina pectoris • Anti-plateletagent • Beta-blocker(e.g., atenolol)&/or calciumchannel blocker (mono: diltiazem/verapamil; combo:MR-nifedipine) • Short-actingnitrate (GTN) • Modifiable risk factormanagement – conservative • Definitive Treatment – Revascularisation Therapy • Percutaneouscoronary intervention (PCI) • Coronary artery bypass graft (CABG) CAD Management • ACS – Common Management • Aspirin 300 mg • O2if saturations <94% • Morphine – only for severe pain • Nitrates – S/L or IV • ECG– dictatesnext stepin management • STEMI Management • delivered within 120 mins of time when thrombolysis couldhave been given • If present after 12hrs & stillhave evidence of ongoingischaemia • Dualantiplatelet therapy prior to PCI – aspirin + prasugrel (or clopidogrel) • Thrombolysis – offeredwithin 12 hrs of symptomonsetif primary PCIcan’t be delivered within 120 mins of time when thrombolysiscouldhave been given CAD Management • NSTEMIManagement • immediate angiographyto those who aren’t high bleeding risk & who aren’t having • Unfractionated heparin if immediate angiography • Further drug therapy prior to PCI or conservative • Dual anti-platelet – aspirin + prasugrel or ticagrelor (or clopidogrel) • GRACE(GlobalRegistry of AcuteCoronary Events)Score • Risk assessment tool • Key decisions made regarding whether management is coronary angiography (with follow-on PCI if necessary) or conservative • Which patientswithNSTEMI/UAshould have coronary angiography (with follow-on PCI if necessary)? • Immediate: clinically unstable (e.g., hypotensive) • Within 72 hrs: GRACE score >3% (i.e., immediate, high or highest risk) • Coronary angiography considered also if ischaemia subsequently experienced after admission CAD Management GRACEScore Parameters Age Predicted6-Month Mortality Riskof Future Adverse Heart rate, bloodpressure CardiovascularEvents ≤1.5% Lowest Cardiac(Killipclass)& renalfunction (serum creatinine) >1.5% - 3% Low >3% - 6% Intermediate Cardiacarrest on presentation >6% - 9% High ECG findings >9% Highest Troponinlevels PassMedicine CAD Management • PCI • Femoral or radial a. access • Guidewire passedup tocoronary aa. under radiological guidance • Angioplasty– cathetercontainingballoon aligned with lesion, inflatedto restorenormal width, re-establishblood flow • Stenting– drug eluting, wire mesh,permanently deployed across lesion, decreasingpost-PCIrestenosisrate • CABG • Circumventingblood around stenosis/occlusion • Anastomosinggraft to coronary a. at sitedistal tolesion • Performed on-or off-pump • PreferredtoPCI in presenceof complexCAD CAD Management NICE – CG126 Stable AnginaManagement https://www .nice.org.uk/guidance/cg126 NICE – NG185 https://www .nice.org.uk/guidance/ng185 CAD Management– NICE CG126 • Revascularisation (CABG or PCI) • In anatomically less complex disease, PCImay be morecost for those with: effective • Stable angina • Symptomsnot satisfactorily controlled • When either procedure appropriate with optimal medicaltreatment • Survival advantageof CABG over • Symptomssatisfactorily controlled PCI for thosewith multivessel with optimal medicaltreatment with disease: LMS or proximal3VDdisease (CABG) • Diabetes • Offer coronary angiography toguide • >65Y/O treatmentstrategy • Anatomicallycomplex3VD,with or without LMS involvement NICE –CG126 CABG vs PCI Trial Data (ESC/EACTS) • NOBEL • Nordic-Baltic-BritishLeft Main Stem Revascularisation Study • 1,201patientsLM disease 1:1PCI or CABG • Primary outcomecompositeat 5-years: death, non-procedural MI, repeat revascularisation,stroke • Statisticallysignificant difference PCIvs.CABG(28% vs.19%,HR1.58(95%CI 1.24-2.01), P=0.0002) • EXCEL • Evaluation of XIENCEvs. Coronary Artery Bypass Surgery for Effectivenessof Left Main Revascularisation Trial • 1,905patientsLM disease of low or intermediate anatomicalcomplexity1:1PCI or CABG • Primary outcomecompositeat 5-years: death, stroke,myocardial infarction • No statisticaldifference afterPCI orCABG (22.0% vs. 19.2%, OR 1.19 (95% CI 0.95-1.50)) https://doi.org/10.1093/ejcts/ezad286 CABG vs PCI Trial Data (ESC/EACTS) • PRECOMBAT • Bypass Surgery Versus AngioplastyUsing Sirolimus Eluting Stentin Patients with Left Main Coronary Artery Disease • 600patient LM disease 1:1PCI or CABG • Primary outcomecomposite,at 10-years: death, MI, strokeor ischaemia- driven target-vesselrevascularisation • No statisticaldifference after PCI or CABG(29.8%vs.24.7%,HR1.25(95%CI 0.93-1.69)) • SYNTAX • PercutaneousCoronary InterventionVersus Coronary Artery Bypass Grafting in Patients with Three-Vesselor Left Main Coronary Artery Disease: 10-year follow-up of themulti-centrerandomised controlled SYNTAXtrial • 1,800patientswith de-novo three-vessel or LM disease • Primary endpointof extendedfollow-up, 10-year all-cause mortality • No statisticaldifference PCI vs.CABG(27%vs.28%,HR0.92(95%CI 0.69-1.22)) https://doi.org/10.1093/ejcts/ezad286 CABG vs PCI Trial Data (ESC/EACTS) • 2022 Joint ESC/EACTS Review of 2018 Guideline Recommendations • Individual patient-datameta-analysis of SYNTAX,PRECOMBAT,NOBEL & EXCEL trials – Sabatine et.al, 2021 • Percutaneous coronary intervention with drug-eluting stentsversuscoronary artery bypass graftingin left maincoronary artery disease4,394patientstotal in sample • Primary outcome: mortalityover 5-years • Mortality over 5-years notstatisticallydifferentfor PCI vs. CABG (11.2% vs. 10.2%, HR 1.10 (95% CI 0.91-1.32), P = 0.33) • Similar observedfor 10-year mortality for PCI vs. CABG (22.4% vs. 20.4%, HR 1.10 (95% CI 0.93-1.29), P = 0.25) https://doi.org/10.1093/ejcts/ezad286CABG vs PCI Trial Data (ESC/EACTS) https://doi.org/10.1016/S0140-6736(21)02334-5 Cumulativeincidenceof all-causedeathsCABG vs PCI Trial Data (ESC/EACTS) https://doi.org/10.1016/S0140-6736(21)02334-5 Cumulativeincidenceof key clinicaloutcomes CABG vs PCI Trial Data (ESC/EACTS) • 2022 Joint ESC/EACTS Review • Individual patient-datameta-analysis of SYNTAX,PRECOMBAT,NOBEL & EXCEL trials – Sabatine et.al, 2021 • Percutaneous coronary intervention with drug-eluting stentsversuscoronary artery bypass graftingin left maincoronary artery disease • 4,394patientstotalin sample • Primary outcome:mortality over 5-years • Mortality over 5-years notstatisticallydifferentfor PCI vs. CABG (11.2% vs. 10.2%, HR 1.10 (95% CI 0.91-1.32), P = 0.33) • Similar observedfor 10-year mortality for PCI vs. CABG (22.4% vs. 20.4%, HR 1.10 (95% CI 0.93-1.29), P = 0.25) https://doi.org/10.1093/ejcts/ezad286CABG vs PCI Trial Data (ESC/EACTS) https://doi.org/10.1093/ejcts/ezad286 5-yearclinicaloutcomeswithPCI vs.CABG inpooledanalysisofrandomizedtrialsCABG vs PCI Trial Data (ESC/EACTS) https://doi.org/10.1093/ejcts/ezad286 Visual representationofpatient outcomes at 5 years after PCI or CABG CABG vs PCI Trial Data (ESC/EACTS) https://doi.org/10.1093/ejcts/ezad286 Practicalrecommendationandclinicalsituationsfavouringpercutaneous coronaryinterventionorcoronaryartery bypass graftinginpatients withleft maindisease CABG vs PCI Trial Data (ESC/EACTS) • 2022 Joint ESC/EACTS Review of the 2018 Guideline Recommendations • (on the Revascularisationof Left Main Coronary Artery Diseasein Patients atLow Surgical Risk& AnatomySuitable for PCIor CABG) • In stablepatients with an indicationfor revascularisationfor LM disease • With coronary anatomysuitable for both procedures & a low predicted surgicalmortality • Concludedthat bothtreatmentoptions are clinically reasonable • Basedon patient preference availableexpertise & local operator volumes Suggested recommendation fortype of revascularizationinstablepatients withleft maindisease,coronaryanatomysuitableforbothprocedures andlow predicted surgicalmortality https://doi.org/10.1093/ejcts/ezad286 Risk Stratification Scores • SYNTAXScore • Synergy Between Percutaneous Coronary Intervention with Taxus& Cardiac Surgery Score • Objective method for quantifying anatomic complexity & severity/extent of multivessel CAD • Surrogate of atherosclerotic burden • Risk stratificationfor facilitatingdecision-making for optimal revascularisation strategy between PCI & CABG for patients with multivessel CAD • Scoring all coronary lesions with: • >50% diameter stenosis • In vessels with diameters >1.5mm • 3 risk groups identified • Low (<23) • Intermediate (23-32) • High (>32) https://doi.org/10.1136/bmhttps://doi.org/10.1161/JAHA.120.020359 Risk Stratification Scores • EuroSCORE • European Systemfor Cardiac Operative Risk Evaluation 1999 (v. II 2012) • Scoringsystemfor predictionof early mortality in cardiac surgery patients in Europe based onobjective riskfactors • Threegroups of risk factors (weighted1, 2 or 3) • Patient-related • Cardiac • Operation-related • Threerisk groups identified basedon EuroSCORE • Low (1-2) • Medium (3-5) • High(6 plus) https://www.euroscore.org/index.php?id=40 CardiopulmonaryBypass • Takes over function of heart & lungs • Circulatory & respiratory support • Delivers oxygen uninterrupted to vital end organs to permit surgery • Essential functions • Oxygenation • Ventilation • Circulation • Temperaturecontrol • Electrolyte balance • Provides myocardial protection & decompresses the heart CardiopulmonaryBypass • Key CircuitSteps • Heparinisation • Insertion of CPB cannulas (aorto- atrial) • Dreservoir (decompression) into • Propel blood from reservoir through heat & gasexchanger via pump • Passes througharterial filter, entering patient via aortic cannula • Aortic cross clampplaced • Separatessystemic& coronarycircuits • Propel potassiumrich cardioplegia solution throughgas exchanger to cardioplegia pump • Caortic root (antegrade) or intoo coronary sinus (retrograde) • Protamineadministeredat end or procedure to reverse heparin CardiacSurgery–Recent Advances & Techniques CABG ConduitChoices • Internal Mammary Artery toits junctionwith femoral vein in groin • First choiceof conduit • Easy toharvest, available, versatile, • Arises from subclavian artery, runs resistanttospasm parallel & lateral to sternum • Increasedgraft failure – stenosis • Associatedwithexcellent long-term (intimal hyperplasia) patency • 10-year patency:61%-71% • Early & latesurvival benefit,& better • Radial Artery even—free survival post-CABG • Secondary choiceof conduit • Resistanttodevelopmentof atherosclerosis • artery blood supply tohand (non-ulnar • 10-year patency:82%-95% dominanthand) • More likely to undergoatherosclerotic • Long Saphenous Vein changes & spasm • One of mostcommonconduitsused • 5-year patency:83%-95% • Runs from anterior tomedial malleolus TSRA Review of CardiothoracicSurgeryCABG ConduitChoices Key Questions inCardiacSurgery CardiacSurgery–Operations onthe Heart & Great Vessels inAdults & Children,2017CABG ConduitChoices Key Questions inCardiacSurgery CardiacSurgery–Operations onthe Heart & Great Vessels inAdults & Children,2017 CABG Procedure • Usually,median sternotomyincision • Aortic cross-clampremoved, heart rewarmed,weaned from CPB • pericardium;LSV harvest ongoing • Top-end anastomoses • Side-biting clamp applied toascending • Pericardium open, staysutures aorta, circular punches taken, top ends placed of vein grafts anastomosed • Heart cannulatedfor CPB • De-airingof grafts & heart • CPBinitiated,aortic cross-clamp • Protamine administered,heart applied, cardioplegia administered decannulated • Coronary targetsidentified • Insertion of pacing wires • Bottom-endanastomoses • Conduits anastomosed end toside on• Drains placed in pericardium to coronary targetsusing continuous Median sternotomyclosed using ‘parachuting technique’res, via sternalwires PasTestCABG Procedure CardiacSurgery–Operations on the Heart & Great Vessels in Adults & Children,2017 Key Questions inCardiacSurgeryQuestion #3 What is the main ion found in cardioplegia solution that induces cardiac arrest, to allow cardiac surgery procedures to be performed? A. Mg2+ B. K+ C. Fe2+ D. Ca2+ E. Na+Question #3 What is the main ion found in cardioplegia solution that induces cardiac arrest, to allow cardiac surgery procedures to be performed? A. Mg2+ B. K+ - high dose potassium chloride is present in cardioplegia solution, potassium-induced cardioplegia – ceases mechanical myocardial contractile activity – diastolic arrest C. Fe2+ D. Ca2+ E. Na+Question #4 Which CABG conduit is associated with the best long term-patency? A. Left internal mammary a. B. Radial a. C. Short saphenous v. D. Long saphenous v. E. Right gastro-omental a.Question #4 Which CABG conduit is associated with the best long term-patency? A. Left internal mammary a. – associated with excellent long-term survival, resistant to atherosclerosis, 10-year patency 82-95% B. Radial a. C. Short saphenous v. D. Long saphenous v. E. Right gastro-omental a.CABG Procedure https://youtu.be/kh1w-qpz8Qo?si=KQCdYUKVnYNz5If4CABG Procedure https://youtu.be/_9QY8e8FM0g?si=BBmls70ROwf8r0BD CABG Complications • Post surgery, patientrequire • Perioperative myocardial infarction (2% monitoring & supportivecarein ICU risk) • Low cardiac output syndrome (5-10% • Overallmortality post CABGis 1-3% risk) • Complications • Arrhythmias (atrial fibrillation 20-40% • Death (2-3% risk) risk) • Stroke (1-5% risk) • Dischargedafter~1 week • Postop bleeding (~20% receive • Slow recovery period – gradual transfusions, 2% undergo re- increasein activity exploration) • Sternal wound infection (1-3% risk) • Straightforwardcases– full recovery • Renal failure (~8% risk) & resumption of normal activities • Neurological complications (type 1 after3 months postop focal 1-3% risk; type 2 global ~3% risk) Zero To TSRA Review of CardiothoracicSurgeryFunctionalParts of the Heart (Internal & External) Gray’s Anatomy For Students, 4 Edition Chambersof the Heart • 4 Chambers • Right Ventricle • 2 atria, 2 ventricle L & R • DeO 2lood from RA • Right Atrium • Trabeculae carnae – supraventricular crest • DeO blood from SVC, IVC & coronary vv. – smooth conus walls • Right auricle • 3x papillary muscles, chordae tendineae • Sinus venarum – crista terminalis – • InterventricularSeptum pectinate muscle • Superior membranous, inferior muscular • Coronary sinus • InteratrialSeptum • LeftVentricle • O2blood from LA • Fossa ovalis • vestibulee carnae, smooth walled • LeftAtrium • 2x papillary muscles • O 2lood from 4 pulmonary vv. • Left auricle • Smooth surface, pectinate muscleFunctionalParts of the Heart (Internal & External) Gray’s Anatomy For Students, 4 EditionFunctionalParts of the Heart (Internal & External) Gray’s Anatomy For Students, 4 EditionFunctionalParts of the Heart (Internal & External) Gray’s Anatomy For Students, 4 EditionFunctionalParts of the Heart (Internal & External) FirstAidfor the USMLE Step 1 2023 Valves of the Heart • Ensureunidirectional flow • Atrioventricular Valves • Close during systole(S1) • Tricuspid • RA →RV • 3 leaflets • Mitral • LA →LV • 2 leaflets • Semilunar Valves (3 cusps) • Close during diastole (S2) • Papillary muscles & chordae tendineae • Pulmonary • RV → PT • Aortic • LV → AAo Gray’s Anatomy For Students, 4 EditionValves of the Heart Thieme Atlas of Anatomy, 4 EditionValves of the Heart Gray’s Anatomy For Students, 4 EditionValves of the Heart Thieme Atlas of Anatomy, 4 Edition Valves of the Heart Valve AnatomicalProjection Aortic Left sternalborder(levelof 3 rib) Pulmonary Left sternalborder(levelof 3 costalcartilage) Mitral(left atrioventricular) Left 4/5 intercostalcartilage th Tricuspid(right atrioventricular) Sternum (levelof 5 costalcartilage) th Thieme Atlas of Anatomy, 4 Edition Auscultation of the Praecordium Valve AuscultationSite Aortic Right 2 intercostalspace (sternalmargin) nd Pulmonary Left 2 intercostalspace (sternalmargin) Mitral(left atrioventricular) Left 5 intercostalspace (midclavicularline)orcardiac apex th Tricuspid(right atrioventricular) Left 5 intercostalspace (sternalmargin) Thieme Atlas of Anatomy, 4 Edition • Heart sounds carried by blood flowing through valve, resulting soundstherefore bestheard downstreamAuscultation of the Praecordium Thieme Atlas of Anatomy, 4 EditionAuscultation of the Praecordium FirstAidfor the USMLE Step 1 2023 ConductionSystem of the Heart • Initiates& coordinates contraction • Conduction Pathway • SA node → • Atria → • AV node → • Bundle of His → • R&L bundle branches → • Purkinje fibres → • Ventricles Thieme Atlas of Anatomy, 4 EditionConductionSystem of the Heart Thieme Atlas of Anatomy, 4 Edition ConductionSystem of the Heart ECGWave / Feature Description P wave Atrial depolarisation PR interval From start of atrialdepolarisationtostart of ventriculardepolarisation(120-200ms) QRS complex Ventriculardepolarisation(<100ms) QT interval Ventriculardepolarisation,mechanicalventricular contraction,ventricularrepolarisation T wave Ventricularrepolarisation J point Junctionbetween end ofQRS complex& start of ST segment ST segment Isoelectric, ventriclesdepolarised U wave Prominentin hypokalaemia,bradycardia FirstAidfor the USMLE Step 1 2023ConductionSystem of the Heart FirstAidfor the USMLE Step 1 2023 ValvularDisease • Encompasses pathologies that selectively affect heart valves • Results in different sound patterns termed murmurs • Murmurs are caused by turbulent blood flow within heart • Four main valvular disorders are: • Stenosisor regurgitation • Aortic or mitral • Stenosis • Narrowing of orifice, inability to openfully • Regurgitation • Incompetence(insufficiency),poorly functioningvalves, backflowof blood Main Causesof ValvularDisease ValvularPathology Causes Aortic Stenosis • Idiopathicage-related calcification (mostcommon,>65Y/O) • Congenitalbicuspid valve(early calcification & stenosis) • Rheumatic heart disease(significantin developing countries) • William’s Syndrome(supravalvularstenosis) • Unicuspid& Quadricuspidvalves • Radiation therapy • Metabolic disorders(e.g.,familialhypercholesterolaemia) Aortic Regurgitation • Acute • Infectiveendocarditis • Aortic dissection • Traumaticruptureof valveleaflets • Iatrogeniccauses(valvuloplastyorTAVI) • Non-nativeaortic valveregurgitation • Chronic • Rheumatic heart disease • Idiopathicage-related weakness(e.g.,calcification) • Congenitalbicuspid aortic valve • Connectivetissuedisorders(e.g.,Ehlers-Danlos&Marfansyndrome) • Infectiveendocarditis • Rheumatologicalconditions Zero To FinalQuesmed Main Causesof ValvularDisease ValvularPathology Causes MitralStenosis • Rheumatic heart disease(mostcommon) • Infectiveendocarditis • Mitralannular calcification (age-related) • Congenitalmitral stenosis(rare) • Metabolic disorders(mucopolysaccharidosis) • Carcinoidsyndrome • Systemicrheumatologicaldisease MitralRegurgitation • Idiopathicweakening ofvalve(age-related) • Ischaemicheartdisease • Infectiveendocarditis • Rheumatic heart disease • Connectivetissuedisorders(e.g.,Ehlers-DanlosorMarfansyndrome) • Myxomatousdisease • Trauma • Systemicinflammatorydisease • Hypertrophiccardiomyopathy • Dilated cardiomyopathy • Prothesisrelated issues Zero To FinalsuesmedMain Causesof ValvularDisease Key Questions inCardiacSurgeryMain Causesof ValvularDisease Key Questions inCardiacSurgery Clinical Presentation of Aortic Stenosis On Examination Findings Symptoms • Maybe asymptomaticfor prolongedperiod(10-20 years) • Exertionaldyspnoea • Exertionalangina • Exertionalsyncopeor presyncope(severe AS) • Mayhaveheart failure • Paroxysmalnocturnaldyspnoea,orthopnoea,dyspnoeaonexertion Signs • Loud mid-to-latepeakingejectionsystolicmurmur (2nd ICS R parasternal) • Radiatestocarotids, accentuatedsittingforward inexpiration • Slow-rising, lowvolumecarotidpulse • Narrowpulsepressure • Soft or absentS2 • Heavingapexbeator systolicthrill • S4 • Heart failuresigns – pittinglowerlimboedema, bilateralbasalcrackles PassMedicineClinical Presentation of Aortic Stenosis Key Questions inCardiacSurgery Clinical Presentation of Aortic Regurgitation On Examination Findings Symptoms • Acute • Suddencardiovascularcollapse • Acute pulmonaryoedema– dyspnoea,sweating, pallor,peripherally vasoconstricted • Chronic • Insidious,sloweronset • Exertionaldyspnoea,orthopnoea,paroxysmalnocturnaldyspnoea • Stableangina Signs • Earlydiastolicmurmur (2 ICS R parasternal) • Accentuatedleaningforward, inexpiration • Soft S1 • Wide pulse pressure • Nailbed pulsation– De Quincke’ssign • Collapsingpulse – Water-hammer pulse • Head bobbing– De Musset’ssign Quesmed Clinical Presentation of Mitral Stenosis On Examination Findings Symptoms • Gradual exertional dyspnoea & reduced exercise tolerance • Haemoptysis • Palpitations (atrial fibrillation) • Chest pain o • Thromboembolism (cerebral or systemic 2 to AF) • Hoarseness • Peripheral oedema • Abdominal discomfort Signs • Mid-to-late diastolic, low pitched rumbling murmur (5 ICS MCL) • Accentuated lyingon left side, inexpiration • Loud S1, tapping apex beat • Malar flush • Low volume pulse • Irregularly irregular pulse – AF • Elevated JVP • Right ventricular heave • Inspiratory crepitations Quesmed Clinical Presentation of Mitral Regurgitation On Examination Findings Symptoms • Acute • Dyspnoea • Dyspnoea on exertion • Fatigue • Weakness • Chronic • Asymptomatic until significant degree of impairment • Fatigue • Exertional dyspnoea Signs • Blowing/whistling, high-pitched, pansystolicmurmur (5 ICS MCL) • Radiates to axilla, accentuated lying on left side, in expiration • Absent or quiet S1 • Thrill in mitral area • Decompensated heart failure – bilateral lung crepitations, raised JVP, S3/S4, peripheral &/or sacral oedema • Acute – acute pulmonary oedema, hypotension, cardiogenic shock • Chronic – significant systolicdysfunction, pulmonary hypertension, atrial fibrillation Quesmed ValvularDisease Murmurs • Aortic Stenosis • Aortic Regurgitation • Crescendo-decrescendoejection • Early diastolic,decrescendo, murmur high-pitched‘blowing’ murmur • Loudestat 2 ICSR StE • Loudestat 2 ICSR StE (aortic • Radiates tocarotids root dilation) • SoftS2 +/- ejectionclick • Loudestat L StE (valvular disease • Weak pulses with delayed peak FirstAidfor the USMLE Step 1 2023 ValvularDisease Murmurs • Mitral Stenosis • Mitral Regurgitation • Following openingsnap • Pansystolic,high-pitched, • Delayed rumbling mid-to-late ‘blowing’ murmur murmur • Loudestat 5 ICSMCL • Reduced interval betweenS2 & OS • Radiates towardsaxilla correlateswith increasedseverity FirstAidfor the USMLE Step 1 2023 ValvularDisease Investigations Valvular Disease Investigations Aortic Stenosis • Bedside • ECG – LVH, L axis deviation • Imaging • CXR – cardiomegaly, pulmonary oedema, calcified aortic valve • Echocardiogram – definitive diagnosis, doppler echo, degree of stenosis, pressure gradient across valve • Exercise testing – true severity of asymptomatic • Cardiac MRI Aortic Regurgitation • Bedside • Throat swab – group A strep • ECG – LVH, p mitrale • Bloods • Inflammatory markers & culture – IE • Autoantibody screen – rheumatology • Imaging • Transthoracic echocardiogram – definitive diagnosis • Cardiac MRI • Invasive cardiac catheterisation Quesmed PasTest ValvularDisease Investigations Valvular Disease Investigations Mitral Stenosis • Bedside • ECG – RVH, R axis deviation, AF, p mitrale • Imaging • CXR – pulmonary oedema, left atrial enlargement • Echocardiogram – definitive diagnosis, degree of stenosis, ventricular filling impairment , doming of leaflets, heavily calcified cusps • Cardiac catheterisation - pressures • Cardiac MRI – valvular vegetations Mitral Regurgitation • Bedside • ECG – LVH, L axis deviation, p mitrale • Bloods • NT pro-BNP – raised in HF, reflecting increased ventricular stress • Imaging • CXR – pulmonary oedema, left atrial enlargement • Echocardiogram – definitive diagnosis, size/pressure of regurgitant jet, size of valve lesions, structural complications Quesmed PasTest Heart Valve Disease Investigations (NG208) • Referral for echocardiography, • Systolicmurmur& exertional with murmur & no other signs or syncope symptoms, if valve disease • Murmur & severesymptoms suspected, based on: (angina or dyspnoea)thought • Natureof murmur relatedto valvular disease • Family history • Referral to specialist after • Age(especially if >75 Y/O) or echocardiography • Medical history • Moderate or severe valve diseaseof any type • Referral for urgent (within 2/52) • Bicuspid aortic valve disease(any specialist assessment or severity) echocardiography, if valve disease suspected: NICE NG208 Heart Valve Disease Investigations (NG208) • Indications for Interventions • Symptomsunmaskedon exercise • Symptomaticsevere valve disease training • Asymptomaticsevere valve disease, • Aortic valve Ca scoreon cardiac CT if severity uncertain if meetcriteria • Aortic Stenosis • Aortic Regurgitation • Vmax (peakaortic jet velocity) • LVEF <55% or • ESD>50mmor ESDI>22mm/m 2 >5m/s 2 • Aortic valve area <0.6cm • LVEF <55% • BNP or NT-proBNP level >2x upper limit of normal NICE NG208 Heart Valve Disease Investigations (NG208) • Indications for Interventions • Mitral Regurgitation • LVEF <60% • ESD>45mmor ESDI>22mm/m 2 • Increase of systolicpulmonaryartery pressure to>60mmHgon exercise testing • Monitoring when no current need for intervention • Asymptomaticsevere valve disease, if interventionsuitable butnot currently needed • Clinical review every 6-12months,with echocardiography • Mild aortic or mitral stenosis • Echocardiography every 3-5 years NICE NG208 Heart Valve Disease Interventions (NG208) • Aortic Valve Disease • Surgery as 1 line in cases of severeaortic stenosis,regurgitationor mixed valve disease, in low to intermediatesurgical riskpatients • TAVI,in cases of non-bicuspidsevereaortic stenosis,in high surgicalrisk patients or thoseunsuitablefor surgery • Mitral Stenosis • Transcathetervalvotomy for thosewith rheumatic severemitral stenosis,if valve suitable for procedure • Surgical mitral valve replacementin cases of severerheumatic mitral stenosis if transcathetervalvotomy unsuitable NICE NG208 Heart Valve Disease Interventions (NG208) • Primary Mitral Regurgitation • Surgical mitral valve repair, in casesof severe primary mitral regurgitation& indicationfor repair, if surgery suitable • Surgical mitral valve replacement,if valve notsuitable for repair • Transcatheteredge-to-edge,if symptomatic& surgeryunsuitable • Secondary Mitral Regurgitation • Surgical mitral valve repair in cases of severesecondary mitral regurgitation who’re having cardiac surgeryfor another indication,if suitable • Surgical mitral valve replacement,if valve notsuitable for repair • Medical management,in cases of heart failure, if surgeryunsuitable • Transcathetermitral edge-to-edge,in cases of heart failure, if surgery is unsuitable& remain symptomaticon medical management NICE NG208 Aortic Stenosis Management • Conservative • Surgical • Asymptomatic& stable • Symptomaticand complex asymptomaticpatients • ‘Watchfulwaiting’ • Regular echocardiography follow-up • Transcatheteraortic valve • Severe – every 6months;mild-to- implantation(TAVI) moderate – yearly; younger patients – • Preferred for those with severe every 2-3years comorbidities, previous heart surgery, • Medical frailty, restricted mobility, >75Y/O • Surgical aortic valve replacement • Symptommanagementof left • Preferred for those <75Y/O & low risk ventricular failure • Diuretics,beta-blockers & ACE inhibitors • Isolatedmedical management– thosenotsuitable for intervention Quesmed Aortic Regurgitation Management • Conservative • Surgical • Severity dependent • Indicatedin symptomaticor • Mild-to-moderatecommonly complexasymptomatic cases monitored,no specifictreatment • IE refractory tomedical therapy • Significantenlargementof AscAo • Medical • To slowrate of aortic root dilatation • Emergencycases • Highrisk (Marfan’s or bicuspid) • Haemodynamicallyunstable • Beta-blockers +/- losartan • Supportive – IV diuretics & vasodilators • Lowers systolicBP • Severe asymptomaticpatients monitoredannually • Significant parameter changes,F/U every 3-6months Quesmed Mitral Stenosis Management • Conservative • Surgical • Asymptomatic& stable – may not • Indicatedin symptomaticcases require treatment • Percutaneousballoon valvuloplasty – • Asymptomatic– regular F/U echo if valve pliable & non-calcified • Medical • Percutaneousmitral valvotomy – • Atrial fibrillation – rate control& moderateseverity anticoagulation • Open valve repair/replacement – severedisease, not toohigh risk, • Diuretics – symptomaticrelief for non-candidatefor PMV pulmonary congestion& peripheral • Valves likely tobe metallic oedema • Long-acting nitrates – help dyspnoea • Beta-blockers – help increase exercisetolerance Quesmed Mitral Regurgitation Management • Conservative • Surgical • Asymptomatic& stable – may not • Definitive in symptomaticcases require treatment • Mitral valve repair (mitral • Asymptomatic– regular F/U echo valvuloplasty) – preferable, preserves components,avoids • Medical prosthesis • Atrial fibrillation – rate control& anticoagulation • Mitral valve replacement • Heart Failure • Mechanical – lifelong anticoagulation, • Diuretics,ACE inhibitors,beta-blockers long-lasting • Bioprosthetic– limited durability, no • AcuteMR – emergency requirement for anticoagulation • Acute pulmonary oedema guidelines management Quesmed TranscatheterAortic Valve Implantation (T AVI) • Minimally invasive procedure • For patients deemed too high risk for open procedure – severe AS • Performed under local or general anaesthesia • Femoral a. access – guidewire inserted • Guidewire passed to aortic valve region under x-ray guidance • Sheath with collapsed heart valve passed over guidewire • Positioned over existing aortic valve – valvuloplasty & bioprosthetic valve deployed • Echocardiography performed to assess for function & perivalvular leakTranscatheterAortic Valve Implantation (T AVI) Master Techniques inSurgery: CardiacSurgery Open HeartSurgery for ValvularDisease • Surgicalapproach for replacement • Mitralregurgitation– valve repair locationdependent favoured • Traditionally median sternotomy • Ring to reduce annulus size & chordae approach tendineae replacement • Minimally invasive – hemi- • Cardiacincision closed sternotomies & mini-thoracotomies • Transoesophageal echocardiography • Placedon CPB performed • Valveaccessvia incision • Assessing valve function & for • Ascending aorta – aortic valve perivalvular leak • Left atrium – mitral valve • Transcutaneouspacing wires placed • Stenotic aortic valve dissectedfrom & mediastinaldrains inserted annulus; new valvesuturedonto • Median sternotomyclosed annulus Teach Me Surgery Aortic Valve Disease Surgery • Choice of Prothesis • Bioprosthetic(pericardiumor porcine)valves • Less durability, higher profiles, lower effective orifice area • Mechanical valves • Higher thromboembolismrisk, require permanent anticoagulation TSRA Review of CardiothoracicSurgeryAortic Valve Disease Surgery TSRA Review of CardiothoracicSurgeryAortic Valve Disease Surgery CardiacSurgery–Operations onthe Heart & Great Vessels inAdults & Children,2017Aortic Valve Disease Surgery Master Techniques inSurgery: CardiacSurgery Aortic Valve Disease Surgery • SAVR Outcomes • Early Complications • Postopmortality ~2-5% • MIor cardiac failure • Haemorrhage • Adult5-year survival postall replacement~80-90% • Infection • 10-yearsurvival rate ~68-89% • Arrhythmias • Stroke • Symptomaticmoderate to severe AS • Late Complications mortality rate – high as 25%in 1-year, 50%in 2-years • Thromboembolic events • Risk Factors • Significant bleed • Advanced age,low EF, CHF, CAD,renal • Structural valvedeterioration failure, endocarditis, female gender, • Paravalvular leak emergency operation, concomitant surgery,previous heart surgery • Haemolysis TSRA Review of CardiPassMedicinegery Mitral Regurgitation Surgery • Intervention • Repair favoured over replacement,if feasible • Repair has an improved survival vs. replacement • 10-yearsurvival of 68%(repair) vs.52%(replacement) • Mostcommonapproach – leftatriotomy • Transseptalapproach – right atriotomy,transseptalincision • Indicated in reop, aortic prosthesis,or smallLA • Complications • Circumflexartery injury, coronary sinus injury, atrioventricular groove disruption TSRA Review of CardiothoracicSurgery Mitral Stenosis Surgery • Interventions • Percutaneousmitral balloon valvotomy • Mitral valve opensurgery TSRA Review of CardiothoracicSurgery Mitral Stenosis Surgery CardiacSurgery–Operations onthe Heart & Great Vessels inAdults & Children,2017 Teach Me SurgeryMitral Stenosis Surgery Master Techniques inSurgery: CardiacSurgery Bioprosthetic& Mechanical HeartValves • Bioprosthetic Valves • Tilting-disc – single tilting disc • St Jude – Bi-leaflet valve • Limited life span - ~10-15 years • Two tiltingmetaldiscs, lowest • Porcine thrombusrisk • Don’trequire anticoagulation • Valve Sounds • S1 click – metallic mitral valve • Mechanical Valves • Good life span - ≥20 years • S2 click – metallic aortic valve • Complications • Requires lifelong anticoagulation – • Thrombusformation warfarin • Infective endocarditis • INR targetrange: 2.5-3.5 • Haemolysis- anaemia • Valve Types • Starr-Edwards– ball in cage • No longerused, highthrombusrisk Zero To Finals Bioprosthetic& Mechanical HeartValves Key Questions inCardiacSurgery Zero To Finals Bioprosthetic& Mechanical HeartValves Valve Parametersto Consider Mechanical Bioprosthetic Age Group Younger(<60 Y/O) Older(>70 Y/O) Durability Longer(lifelong) Shorter(~10-15 years) Anticoagulation Required Not required (Initiallyheparin,thenlifelong warfarin) Teach Me SurgerySurgical Aortic Valve Replacement https://youtu.be/KASDvXtmqBI?si=BULJ6JfBHIRqBlx8Surgical Mitral Valve Replacement https://youtu.be/hQzsDp9H2Nk?si=pb6d2hWJYVqLE86T Relevant NICE Guidance • CG126 – StableAngina: Management • https://www.nice.org.uk/guidance/cg126 • NG185 – AcuteCoronary Syndromes • https://www.nice.org.uk/guidance/ng185 • IPG377 – Off-PumpCoronary Artery Bypass Grafting • https://www.nice.org.uk/guidance/ipg377 • TA71– Guidance on the useof Coronary Artery Stents • https://www.nice.org.uk/guidance/ta71 • IPG494 – EndoscopicSaphenous Vein Harvest for Coronary Artery Bypass Graft • https://www.nice.org.uk/guidance/ipg494 • NG208 – Heart Valve Disease Presentingin Adults:Investigation & Management • https://www.nice.org.uk/guidance/ng208 • IPG586 – TranscatheterAortic Valve Implantationfor AorticStenosis • https://www.nice.org.uk/guidance/ipg586 References • Gray’s Anatomy for Students, 4 Edition • Master Techniques in Surgery: Cardiac Surgery • Thieme Atlas of Anatomy, 4 Edition • https://doi.org/10.1093/ejcts/ezad286 • First Aid for the USMLE Step 1, 2023 • https://doi.org/10.1136/bmjopen-2022-062378 • PassMedicine • https://doi.org/10.1161/JAHA.120.020359 • Pastest • https://doi.org/10.1016/S0140-6736(21)02334-5 • QuesMed • https://www.euroscore.org/index.php?id=40 • Geeky Medics • https://bjcardio.co.uk/2016/08/optimal-angiographic-views-for- • Zero To Finals invasive-coronary-angiography-a-guide-for-trainees/ • https://keck2.usc.edu/cardiovascular-medicine-division/wp- • Teach Me Surgery content/uploads/sites/140/2017/10/Basic-Coronary-Angiography_All- Slides.pdf • TSRA Review of Cardiothoracic Surgery • NICE CG126 • https://youtu.be/kh1w-qpz8Qo?si=KQCdYUKVnYNz5If4 • NICE NG185 • https://youtu.be/_9QY8e8FM0g?si=BBmls70ROwf8r0BD • https://youtu.be/KASDvXtmqBI?si=BULJ6JfBHIRqBlx8 • NICE NG208 • Key Questions in Cardiac Surgery • https://youtu.be/hQzsDp9H2Nk?si=pb6d2hWJYVqLE86T • Cardiac Surgery – Recent Advances & Techniques • Cardiac Surgery – Operations on the Heart & Great Vessels in Adults & Children, 2017 Thank you for listening Any Questions? Acknowledgements Thank you to Abderrahmane El Guernaoui Mr Peter MhanduSee future sessions and watch recordings at: SUPTA.UK Clinical Case Q#1 A 65-year-old male patient presents toyour practice complaining of chest pain that has spreading down his left arm also. He says that he can’t catch his breath when this is chest, occurring. The symptoms come on whenever he exerts himself walking up hillsor the stairs,though they improve with rest. He has a past medical history of high blood pressure, type 2 diabetes, and is a current smoker. On examination there are no abnormal findings. finds that there is 70% stenosis of the proximal left anterior descending coronary artery.t Therefore, he willundergo an elective coronary artery bypass graft procedure. Which conduit vessel is recommended as first choice to anastomose distally to the stenosis of the left anterior descending artery? A) Radial artery B) Left internal mammary artery C) Long saphenous vein D) Right gastroepiploic artery E) Short saphenous vein Clinical Case Q#1 A65-year-old male patient presentsto your practice complainingof chest pain that has been ongoingfor He saysthat he can’t catchhis breath when this is occurring. The symptomscomeon whenever he exerts also. himself walkingup hills or the stairs,thoughthey improve with rest.He has a pastmedical history of high blood pressure,type 2diabetes, and is a current smoker. Onexaminationthere are no abnormal findings. Ashe is clinically suspected to havestableangina,CT coronary angiographyis performed. Itfinds that an elective coronary artery bypass graft procedure. Which conduit vessel isrecommended as first choice to anastomosedistallyto the stenosisof the left anterior descending artery? A) Radialartery – second choice of conduit, as it is morelikely to undergo atherosclerotic changes and spasm B) Leftinternalmammaryartery– firstchoice of conduit, as it is associatedwith excellent long-term patency C) Long saphenous vein – one of the mostcommonconduits usedfor CABGprocedures, though there is increased graft failure with these conduits D)Rightgastroepiploic artery – not typically used in an initial CABGoperation, thoughtmaybe utilized in a redo procedure E) Short saphenousvein – this vessel is not typically used in a CABGprocedure, as the long saphenousvein is preferred Clinical Case Q#2 A 67-year-oldmanis BIBAto ED, presentingwith severechest pain and shortness of breath,that has acutely developed over the pasthour. His symptomsstarted when he got up this morning and have gottenworse. He feels nauseous and light- history of hypertension anddiabetes. On examination, thepatient is in distress and profusely sweating.His pulse is 110bpm, respirationrateis 25/min,blood pressureis 150/76mmHg, and oxygen saturationsare98%on room air. The patient is suspectedtobe having a myocardialinfarction, soan ECGis performed. toproduce theseischaemicchanges?, IIIand aVF. Which area of the heart has infarcted A) Anteroseptal B) Posterior C) Anterolateral D) Inferior E) Lateral Clinical Case Q#2 A 67-year-oldmanis BIBAto ED, presentingwith severechest pain and shortness of breath,that has acutely developed over the pasthour. His symptomsstarted when he got up this morning and have gottenworse. He feels nauseous and light- history of hypertension anddiabetes. On examination, thepatient is in distress and profusely sweating.His pulse is pulse is 110 bpm, respirationrate is 25/min, blood pressureis 150/76mmHg, and oxygen saturationsare98%on room air. The patient is suspectedtobe having a myocardialinfarction, soan ECGis performed. produce these ischaemicchanges? IIIand aVF. Which area of the heart has infarctedto A) Anteroseptal– V1-V4(leftanterior descending) B) Posterior – tallRwaves V1-V2(oftenleft circumflex, also right coronary) C) Anterolateral– V4-V6,I, aVL(left anteriordescending or left circumflex) D) Inferior– II, III,aVF (right coronary) E) Lateral– I, aVL, +/- V5-V6(leftcircumflex) Clinical Case Q#3 breathlessnessandchest discomfort on exertion, withgradually worsening with fatigue. He recalledfaintingfor a fewminutes the other week when he chased afterhis grandson in thegarden. On examinationhis blood pressureis 142/113 mmHg, pulse is 76 bpm, respirations are17/minand oxygen saturationsare96% on room air. It is noted thathe has a slow-risingpulse. On auscultation,a harsh, sternalborder, 2 intercostalspace,that radiates tothe carotids. Basedupon the history and clinicalfindings, whatvalvular diseaseis this patient sufferingfrom? A) Mitral regurgitation B) Aortic stenosis C) Mitralstenosis D) Aortic regurgitation E) Tricuspid regurgitation Clinical Case Q#3 A77-year-old manwith ahistory of hypertension presentsto your practice with breathlessnessand chest discomfort on exertion, with gradually worseningfatigue. He recalled fainting for afew minutes the other week when he chased after his grandsonin the garden.On examinationhis blood pressure is 142/113mmHg,pulseis pulse. Onauscultation,a harsh,ejection systolic,crescendo-decrescendo murmuris heard,loudest at his rightng sternal border, 2 intercostalspace,that radiates to the carotids.Basedupon the historyand clinical findings, what valvular diseaseis this patientsuffering from? A) Mitral regurgitation– pan-systolic,high-pitched, whistlingmurmur,thatradiates to the left axilla,murmurbest heard at apex B) Aorticstenosis– harsh,high-pitched, crescendo-decrescendo, ejection systolicmurmur,radiating tothe carotids,best heard atright 2 ICS accompanied by a decrescendo diastolicrumble with pre-systolicaccentuation) murmurbest heard with bell in left lateral position atapex D)Aortic regurgitation– early diastolic,soft murmur(high pitch, blowing,diastolic, decrescendo murmur),best heard sitting/leaningforward in expiration, bestheard atleft parasternal region,3 intercostalspace E) Tricuspid regurgitation– pan-systolicmurmur,split second heart sound,raised JVP,thrill in tricuspid area AdditionalVideo Resources • TAVI • Coronaryangiography&catheterisation • https://youtu.be/Jtek8004jAA?si=3Xd9bRzLacISLtev • https://youtu.be/kY5gKdFWT3k?si=Ciy8ia_DQzg5YZWu • CABG • Coronaryangioplasty • https://youtu.be/kxc22Fjd1NQ?si=NjoIiTShOI9AvANR • https://youtu.be/N7nghr9TpSU?si=hcX7dS8KnHtEmecA • MI due to atherosclerosis • Coronaryangioplasty(radial) • https://youtu.be/wbShOXhO6p8?si=bV9Z8xCwJmURnNi5 • https://youtu.be/bzasYRhmOWg?si=aHHIejt3xXgtVuM6 • Minimallyinvasiveroboticmitralvalverepair • Coronaryangioplasty(femoral) • https://youtu.be/LhhWu4JCrBw?si=ZLQHfIMR6N2YAb47 • https://youtu.be/MKRGgX5rYbY?si=Qie06W1IfHAzaBRR • ACS & MI • What iscoronaryangioplasty • https://youtu.be/afYCN3Upy_w?si=HkrrPfw8mcF72jvP • https://youtu.be/j9VY6FSIr64?si=iA0GIb4d4o_-61qL • Echocardiogram • TAVR / TAVI • https://youtu.be/Kirg2GuESsE?si=dv3WdbCasyjq9GqI • https://youtu.be/f4cswXjXYnw?si=TSTgX43A5tSRqENS • Aortic valvereplacement • https://youtu.be/5jLfPlQBYuw?si=a5ScSOPhnoOQaRiH • CABG • https://youtu.be/3Nf6Q2skGOM?si=fLp0nf4JzCVsE5U4