Computer generated transcript

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

Cardiothoracic Surgery Arifa Qureshi Y3 Med student at BHTLearningObjectives • Basic anatomy of the heart and clinical significance • Electrical conduction of the heart • Valvular heart disease and murmurs • Presentations and risk factors for coronary artery disease • Management of ACS (PCI, CABG)AnatomyoftheHeart • 4 chambers – R Atrium, R Ventricle, L Atrium, L Ventricle • IVC/SVC à RA à RV à PA à Lungs à PV à LA à LV à Aorta Blood Flow throughthe HeartLayersoftheHeart 1. Endocardium 2. Myocardium 3. Serous Pericardium 1. Epicardium (visceral) 2. Pericardial space 3. Pericardium (parietal) 4. Fibrous PericardiumInfectiveEndocarditis • Infection of the endocardium • Causative organisms: • staphylococcus aureus • streptococcus viridians • staphylococcus epidermis in valve replacement • S+S • Fever, chills, dyspnea, chest pain, muscle aches • Aortic regurgitation murmur • Diagnosis - Modified Duke Criteria – 3 blood cultures,splinter hemorrhages,Janeway lesions,Osler’s nodes,fever • Treatment • Antibiotics depending on causative organismMyocarditis • Inflammation/infection of myocardium • Causes: • Viral - Adenovirus coxsackie B, HIV • Lyme disease • Protozoa - Chagas disease • S+S • Dyspnea • Chest pain • Arrythmias • Diagnosis – high CRP,troponin,BNP ,arrythmias on ECG • Treatment • Treat underlying causePericarditis • Inflammation of pericardium • Causes: • Viral - Coxsackie B • Bacterial – TB • CTD – SLE or RA • S+S • pericardial rub pain better on leaning forward • ECG changes = saddle ST changes and PR depression • Diagnosis – raised inflammatory markers and sometimes troponin • Treatment • NSAIDs + colchicinePericarditisECGBloodSupplyofHeart • Right Coronary Artery – Acute Marginal,SA nodal,conus • Left Anterior DescendingArtery – Diagonal and septal branches • Left Circumflex Artery – Marginal Obtuse • Posterior Interventricular Artery – Depends on dominant circulation (RCA (about 80% individuals),LCA (20-25% individuals)BloodSupplyofHeart Coronary Arteries AreaofSupply Right Coronary Artery SA node,AVnode,Right atrium,right ventricle,Apex Left Anterior Descending Anterior interventricular septum,right ventricle,left ventricle Left circumflex Left atrium,Left ventricle Posterior interventricular Posterior interventricular septumCoronaryAngiogram • Send dye through the radial/femoral artery to see patency of coronary arteries through Xray imagingCoronaryAngiogram • Send dye through the radial/femoral artery to see patency of coronary arteries through Xray imagingCardiacVeins • Small, middle and great cardiac veins • All veins drain into coronary sinus which opens into the RAElectricalConductionoftheHeart • SA node à AV Node à Bundle of His à LBB and RBB à Purkinje FibresTypesofCellsinHeart • Pacemaker Cells Three phases (Phase 4, 0, 3) • Five phasestes (Phase 0, 1, 2, 3, 4)ValvularProblems • Semilunar valves – bw ventricle and blood vessel (aortic and pulmonic) • Atrioventricular valves – bw atria and ventricles (tricuspid and mitral) • 2 types of problems: • Stenosis – narrowing of the valve • Regurgitation – retrograde flow of blood through valveHeartMurmurs • Normal heart sounds – S1 and S2 • Murmurs – added heart sounds • Systolic – between S1 and S2 • Diastolic – between S2 and S1 • Descriptions • Timing – early, mid, or late • Sounds – crescendo, decrescendo, ejection, rumbling • Radiation – axilla, carotids, apex • Intensity – Grade I - VIHeartValves • Aortic – 2 ICS Right sternal edge nd • Pulmonary – 2 ICS Left sternal edge • Erb’s Point – 3 ICS Left sternal edge • Tricuspid – 4 ICS Left sternal edge • Mitral/Apex – 5 ICS left midclavicular lineAorticStenosis • Path – stenosis of aortic valve • Causes: calcification/wear and tear, bicuspid AV , rheumatic HD, HOCM • S&S – syncope, angina, dyspnoea (remember SAD), narrow PP • Murmur – ejection systolic murmur radiates to carotids • Management: • If symptomatic or valvular gradient > 40 mmHgà aortic valve replacement (metal or prosthetic) • If symptomatic but not fit for surgery à TAVI • Child or severe aortic stenosis à balloon valvuloplastyAorticRegurgitation • Path – retrograde blood flow fromaorta to left ventricle through aortic valve • Causes:CTD (EDS/Marfans),RHD,IE,Aortic root dilation,bicuspid AV • S&S – fatigue,dyspnoea,collapsing pulse,wide PP ,Quinke’s sign,De Musset’s sign • Murmur – early diastolic murmur increased with handgrip and expiration • Management: • If symptomatic à aortic valve replacement • If asymptomatic but have LV dysfunction à aortic valve replacementMitralStenosis • Path – stenosis of the mitral valve • Causes: Rhematic heart disease,Rare = mucopolysaccharidoses, carcinoid and endocardial fibroelastosis • S&S – dyspnoea,haemoptysis • Murmur – mid diastolic murmur with opening snap better heard on left lateral decubitus position on expiration with bell • Management: • If have atrial fibrillation à require anticoagulation (warfarin) • If symptomatic à percutaneous mitral balloon valvotomy or mitral valve surgery (commissurotomy, or valve replacement)MitralRegurgitation • Path – retrograde blood flow fromleft ventricle to left atriumthrough mitral valve • Causes: IHD or post MI,MVP ,IE,RHD • S&S – asymptomatic,arrythmias,pulmonary hypertension and oedema • Murmur – pansystolic murmur best heard on left lateral decubitus position on expiration with diaphragm • Management: • If acute à medical - nitrates, diuretics, positive inotropes and an intra-aortic balloon pump • If heart failure à ACE inhibitors, beta-blockers and spironolactone • If acute, severe regurgitation à surgery (repair or replacement)TricuspidRegurgitation • Path - retrograde blood flow from right ventricle to right atrium through tricuspid valve • Causes: RV infarction, pulmonary hypertension, RHD, IE, Ebstein • S&S – giant V waves in JVP, left parasternal heave, hepatomegaly • Murmur - pansystolic murmur best heard on left lateral decubitus position on expiration with diaphragm at tricuspid area • Management: • If symptomatic à valve replacementPulmonaryStenosis • Path – stenosis of pulmonic valve • Causes: Noonan syndrome, Tetralogy of Fallot • S&S – raised JVP with giant A waves, peripheral oedema, thrill • Murmur - ejection systolic murmur loudest in the pulmonary area with deep inspiration with split second heart sound • Management: • Treat congenital heart defects with surgical treatmentCoronaryArteryDisease Steps of Pathophysiology: 1. Initial endothelial damage due to smoking, hypertension or hyperglycaemia 2. Changes to the endothelium happen including pro-inflammatory, pro- oxidant, proliferative and reduced nitric oxide 3. Fatty infiltration of the subendothelial space by low-density lipoprotein (LDL) particles 4. Monocytes migrate from the blood and differentiate into macrophages. These macrophages then phagocytose oxidized LDL, turning into large 'foam cells’. 5. Sintima results in formation of a fibrous capsule covering the fatty plaque 6. Rupture of the fatty plaque then leads to thrombus formation à ACSCoronaryArteryDiseaseRiskFactors Modifiable Non-Modifiable SMOKING AGE ALCOHOL GENDER(MALE) CO-MORBIDITIES(DIABETES, AF, HTN, CKD, FAMILY HISTORY DYSLIPIDEMIA, RA, SLE) OBESITY ETHNICITY HIGH NON-HDL ORLOWHDL CHOLESTEROL SEDENTARY LIFESTYLEECG–AreasofIschemiaECG–AreasofIschemiaStableAngina • Path – exertion = faster HR = short diastole = less coronary blood flow (stable plaque) • Features: • Chest pain on exertion (exercise, walking) • NO chest pain at rest • NO ECG changes or raised troponin • Relieved with nitrates • Treatment: 1. Acute = GTN 2. Beta Blockers 3. Beta blockers + dihydropyridine CCB 4. Long-acting nitrates or ivabradineUnstableAngina • Path – ruptured plaque à thrombus forms à partially blocked artery à chest pain • Features: • Chest pain at rest • NO ECG changes • RAISED troponin • Treatment: 1. Treat as NSTEMI while waiting for troponin 2. MONA – morphine, oxygen, nitrates, aspirinNon-STElevationMyocardialInfarction(NSTEMI) • Path – ruptured plaque à thrombus forms à completely blocked artery à subendocardial ischemia • Features: • Chest pain at rest • ECG changes = ST depression and T wave inversion • RAISED troponin • Treatment: 1. MONA – morphine, oxygen, nitrates, aspirin 2. Fondaparinux if not doing PCI 3. Calculate GRACE score (if >3% do PCI within 72 hrs)NSTEMIECGSTElevationMyocardialInfarction(STEMI) • Path – ruptured plaque à thrombus forms à completely blocked artery à transmural ischemia • Features: • Chest pain at rest • ECG changes = ST elevation or new LBBB, reciprocal changes in opposite leads • RAISED troponin • Treatment: 1. MONA – morphine, oxygen, nitrates, aspirin 2. Immediate PCI within 120 mins (give prasugrel if going for PCI) 3. If no PCI, give ticagrelor and thrombolysis– tPASTEMIECGPercutaneousCoronaryIntervention • Coronary angiogram reveals areas of blockage in coronary arteries which are opened with drug-eluting stentsCoronaryArteryBypassGraft • CABG – a surgical procedure taking a blood vessel from another part of the body (chest, leg or arm) and attaching it to the coronary artery above and below the narrowed area or blockage creating a graft to allow blood flow • Vessels used: Great saphenous vein, left internal mammary artery, radial artery • Indications: triple vessel disease, left main vessel disease >50%, significant disease and symptoms despite maximal medical therapyCABGCABGComplications • Common complications to consider post CABG 1. Atrial Fibrillation 2. Bleeding during or after surgery 3. Infection at incision sites 4. Thrombus Formation – stroke, MI or PE 5. Acute Renal Failure Post-operative medications = Dual antiplatelet therapy (Aspirin + P2Y12 inhibitor (clopidogrel))References • Heart anatomy (2022) The Texas Heart Institute®. Available at: https://www.texasheart.org/heart-health/heart-information-center/topics/heart-anatomy/ (Accessed: 22 January 2025). • Smartspacer (no date) Human heart anatomy vector art, icons, and graphics for free download, Vecteezy. Available at: https://www.vecteezy.com/free-vector/human-heart- anatomy (Accessed: 22 January 2025). • The heart wall (no date) TeachMeAnatomy. Available at: https://teachmeanatomy.info/thorax/organs/heart/heart-wall/ (Accessed: 22 January 2025). • Diaz, Dr.G. (2018) Skin findings in endocarditis - skin findings include ..., GrepMed. Available at: https://www.grepmed.com/images/437/janewaylesions-endocarditis- oslersnodes-dermatology-splinter (Accessed: 22 January 2025). • 22 January 2025).. (no date) Myocarditis, The Harley Street Heart & Vascular Centre. Available at: https://www.harleystreet.sg/kb/about-heart-disease/myocarditis/ (Accessed: • qenq0 (2023) Understanding infective pericarditis, First Cardiology Consultant. Available at: https://firstcardiology.org/understanding-infective-pericarditis/ (Accessed: 22 January 2025). • Person, Steven Lome, M. and Lome is Cardiology Medical Director of Montage Medical Group in Monterey County, C. (2017) Pericarditis ECG (example 2), Learn the Heart. Available at: https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-archive/pericarditis-ecg-example-2 (Accessed: 22 January 2025). • representation-of-normal-coronary-artery-and-its-branches-adapted-from-Drake_fig1_338717403 (Accessed: 22 January 2025).ble at: https://www.researchgate.net/figure/figurative- • Howwide are your arteries? (no date) Heart Foundation NZ. Available at: https://www.heartfoundation.org.nz/your-heart/heart-tests/coronary-angiography (Accessed: 22 January 2025). • MacDonald, Dr.M.R. (no date) Coronary angiogram, The Harley Street Heart & Vascular Centre. Available at: https://www.harleystreet.sg/services/cardiac/cardiac- tests/coronary-angiogram/ (Accessed: 22 January 2025). • Coronary angiography - sozocardiology - dr Ooi Yau Wei interventional cardiologist (2021) SozoCardiology. Available at: https://www.sozocardiology.com/heart- investigations/coronary-angiography-and-left-ventriculography/ (Accessed: 22 January 2025). • (No date) Foundation for Circulatory Health. Available at: http://www.ffch.org/which-valves-and-arteries-to-open.html (Accessed: 22 January 2025). • (No date a) Amboss. Available at: https://www.amboss.com/us/knowledge/heart(Accessed: 22 January 2025). • EZmed (2025) Conduction system of the heart: Step-by-step labeled diagram and pathway, EZmed. Available at: https://www.ezmedlearning.com/blog/conduction-system (Accessed: 22 January 2025). • https://www.ezmedlearning.com/blog/actionpotential (Accessed: 22 January 2025).and pacemaker phases and steps, EZmed. Available at:References • (No date) YouTube. Available at: https://www.youtube.com/watch?v=IrWEAucHoA0 (Accessed: 22 January 2025). • https://www.gastroepato.it/en_auscultazione_cuore.htm (Accessed: 22 January 2025).o in tema di medicina interna. Available at: • Heart murmur (2024) Wikipedia. Available at: https://en.wikipedia.org/wiki/Heart_murmur(Accessed: 22 January 2025). • Atherosclerosis (2025) Wikipedia. Available at: https://en.wikipedia.org/wiki/Atherosclerosis (Accessed: 22 January 2025). • Xianfeng Liu a et al. (2020) Targeting foam cell formation andmacrophage polarization in atherosclerosis: The therapeutic potential of Rhubarb, Biomedicine & Pharmacotherapy. Available at: https://www.sciencedirect.com/science/article/pii/S0753332220306260 (Accessed: 22 January 2025). • RichardN. Fogoros, M. (2024) Atherosclerosis: Causes, effects, and treatment, Verywell Health. Available at: https://www.verywellhealth.com/what-is-atherosclerosis- 1745908 (Accessed: 22 January 2025). • education/m4-curriculum/group-m4-approach-to/shortness-of-breath/acute-coronary-syndromes (Accessed: 22 January 2025).filiates2/cdem/for-students/online- • HASE, Dr.N. et al. (no date) Stemi & NSTEMI: A Nurse’s comprehensive guide, HealthAndWillness. Available at: https://healthandwillness.org/stemi-nurses-guide/ (Accessed: 22 January 2025). • Angina treatment & symptoms, the causes of angina (2024) The Keyhole Heart Clinic. Available at: https://www.thekeyholeheartclinic.com/angina/ (Accessed: 22 January 2025). • (No date) ECG interpretation. Available at: https://www.abdn.ac.uk/medical/elf/courses/view/146858/ecg-interpretation/1/page23 (Accessed: 22 January 2025). • professional, C.C. medical (2024) Percutaneous coronary intervention (PCI), Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/treatments/22066- percutaneous-coronary-intervention (Accessed: 22 January 2025). • Leach, P. author:DrT. et al. (2020) Coronary artery bypass grafting (CABG), almostadoctor. Available at: https://almostadoctor.co.uk/encyclopedia/coronary-artery- bypass-grafting-cabg (Accessed: 22 January 2025). • Coronary artery bypass surgery: Purpose and more (no date) Medical News Today. Available at: https://www.medicalnewstoday.com/articles/322443 (Accessed: 22 January 2025). • Coronary artery bypass surgery (2024) Wikipedia. Available at: https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery (Accessed: 22 January 2025). • Available at: https://www.sciencedirect.com/science/article/abs/pii/S0735675718307459 (Accessed: 22 January 2025).ans, The American Journal of Emergency Medicine.