Heart Disease
SUGGESTED READINGS HEART DISEASE Current Surgical Diagnosis & Treatment, 12th Edition, pgs. 201-203, 390-419, 809-816. OBJECTIVES HEART DISEASE 1. Describe the basic coronary anatomy of the heart, and oxygen extraction rates under resting and stress conditions. What constitutes a significant obstruction? 2. Given that each patient should be considered on an individual basis, what situations might be better addressed with surgery over medical management in considering long-term survival? 3. Name at least five factors that should be considered for calculating operative risk in patient being counseled for (or against) cardiac surgery. 4. What is the most common cause of mitral valve stenosis? What is the natural history of untreated mitral valve stenosis in the asymptomatic patient? 5. What are the common causes of mitral regurgitation? Which patients should be treated surgically? 6. What is the classic triad in a patient presenting with aortic stenosis? How is severity graded? Which patients should have valve replacement? 7. What are the two major categories of prosthetic valves and the advantages of each? 8. Illustrate the anatomic distinction between Stanford type A and B dissections. Similarity, distinguish between DeBakey classes I, II, and III. 9. What cardiac tumors are most common? What is the most common primary cardiac tumor? 10. What are some of the more common complications after cardiac surgery – that are common enough to include in a discussion during preoperative counseling? Name at least five. CASE HISTORIES HEART DISEASE 1. A 60 year old man presents to the cardiology service with chest pain while at rest for the past week. Previous to this week, his pain only occurred with moderate exertion and was relieved by sublingual nitroglycerine. His past medical history is notable for diabetes, hypertension and obesity. He is employed as an office manager and smokes one pack cigarettes daily. He is admitted to cardiology. Serial cardiac enzymes are within normal limits. His EKG shows normal sinus rhythm. His chest XRay shows a 1 cm right lower lung nodule. He is taken to the cath lab and is found on cardiac catherization to have diffuse, but graftable 3 vessel disease and an EF of 35%. We are asked to see and counsel this patient for CABG. • Would you counsel this patient for surgery? Why or why not? • What management options does he have for his chest pain aside from CABG? • What risk factors does he have for surgery? What other information would be helpful in calculating his risk? • What are the potential complications that could occur with surgery? • If this patient was 40 years old, would your management differ? • If this patient was 80 years old, would your management differ? • Does the 1 cm nodule impact your management of this patient? If so, how? 2. A 50 year old man presents with worsening shortness of breath and chest pain for the past six months presents to the ED. He denies any medical problems, but has not been seen regularly by a MD. He is a nonsmoker. He is found on exam to have a III/VI systolic murmur over the precordium. His labs are normal as is his chest x-ray. He is sent to a cardiologist who performs an echocardiogram, which shows severe aortic stenosis (est. valve area <1.0). He ultimately undergoes cardiac catherization which shows a valve gradient of 40 mm Hg (est. valve area 1.3cm2). No coronary artery disease. We are asked to see and counsel him for aortic valve replacement. • How would you grade his degree of aortic stenosis? • Would you advise him to have his valve replaced? What options does he have? • If he were to undergo replacement, what valve type would you recommend and why? • Does the risk of valve surgery differ than CABG? If so, how? • Would your recommendations change if he was a 75 year man? Would they change if the patient was a 25 year old woman? 3. A 32 year old woman presents with a soft diastolic murmur heard on routine physical exam. Her EKG is essentially normal. She is sent for echocardiogram, which is read as mitral stenosis, with a slightly enlarged left atrium and a transvalvular gradient across the mitral valve of 8 mm Hg. Normal EF. She is employed as a migrant farm worker. She is sent to you by the clinic MD for counseling. • What is the most likely etiology of her mitral stenosis? • Would you counsel her for surgery? What are her alternative options? • If she were to decide for surgery, would you recommend that she undergo valve repair instead of replacement? • What additional information would be of valve in deciding what type of valve replacement would be best for this patient? 4. A 75 year old man presents to the emergency with sudden back pain and shortness of breath. He was diagnosed with hypertension but has not seen his doctor regularly for the past few years. He denies any other known medical problems. He is not currently taking any medication. He is retired from the trucking business. He reports 1 ppd tobacco use for the past 50 years. He is noted in the ER to have a BP of 160/70 and a normal EKG. He is taken to the CT scanner for a PE protocol. No PE is found; however, he is found on CT scan to have a tear in the mid descending aorta that extends to the aortic bifurcation with perfusion in both lumens. His left kidney receives its blood flow from the false lumen. PRACTICE SELF-ASSESSMENT QUESTIONS 1. Mitral valve repair for mitral regurgitation commonly involves which of the following: a) Placing an annuloplasty ring to maintain/restore integrity of the mitral annulus b) Complete removal of the posterior leaflet of the valve c) Repairing the papillary muscle support of the valve d) Resecting part of the anterior leaflet. 2. Which of the following valve types is most resistive towards infection? a) Porcine b) Pericardial c) Mechanical d) Allograft (i.e., cadaveric cryopreserved valves) 3. Which of the following statements regarding aortic dissections is/are true a) Type A dissections involve the ascending aorta b) Type II dissections involve the descending aorta c) Type III dissections involve the entire aorta d) answers a and c are correct 4. Which of the following statements regarding coronary anatomy is(are) true a) The PDA (posterior descending artery) is usually a branch of the right coronary artery b) The circumflex vessel gives rise to acute marginal branches c) Diagonal vessels supply the posterior distribution of the left heart d) answers a and b are correct 5. Type B dissection is a surgical emergency because of the potential risk of: a) Tamponade b) Coronary artery occlusion c) End organ ischemia d) None of the above 6. The most ominous sign of late aortic stenosis is: a) Angina pectoris b) Palpitations c) Syncope d) Congestive heart failure 7. A 50 year old dialysis patient needs a mitral valve replacement for mitral stenosis. What type of valve is preferred? a) Mechanical b) Tissue c) Allograft (i.e., a cadaveric homograft) d) Any of the above will serve equally 8) Tumors involving the heart: a) Are usually malignant b) Only need to be resected if left sided to reduce the risk or tumor embolization and stroke c) Usually arise in the left atrium in the case of atrial mxyomas d) Answers a and c Students who want a critique of their practice self-assessment should submit their answers to me at: jquin@siumed.edu. Please number your answers and try not to send them to me the night before the exam.
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