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3a
Dr. Villanueva
November 10, 2014
Cardiac Assessment
a. Cardiac Function Disability
b. Diagnostics and Ancillary Procedures
II. Coronary Artery Disease
a. Coronary Anatomy
b. Coronary Angiography
c. Viability Studies
d. Revascularization
III. Valvular Heart Diseases
a. Mitral Valve Diseases
i. Mitral Stenosis
ii. Mitral Regurgitation/Insufficiency
iii. Mitral Valve Operative Techniques
b. Aortic Valve Diseases
i. Aortic Stenosis
ii. Aortic Regurgitation/Insufficiency
c. Tricuspid Valve Disease
i. Tricuspid Stenosis and Insufficiency
ii. Multivalve Disease
*Most of the things discussed here are from Schwartz and powerpoint
CARDIAC ASSESSMENT
Symptoms
o Chest discomfort, fatigue, edema, dyspnea, palpitations, syncope.
Family history
Personal habits
Functional capacity
Review of systems
Physical examination foundation for evaluation with acquired cardiac
diseases (ACD) requiring surgical intervention.
ECG
o Summary of electrical impluses generated by the heart
o Used to check for rhythm disturbances, heart block, ventricular
strain, signs of atrial and ventricular enlargement, and signs of
ischemia
Stress ECG- requires a patient to exercise to a target rate to help
diagnose ischemic pathologies
Chest X-ray
o detect pulmonary pathology, sequelae of heart failure, as well as
hardware from previous procedures (e.g. prosthetic valves)
a) PA view
Page 1 of 15
SURGERY 4.3A
1.
3D ECHO
Useful in the evaluation of mitral regurgitation
2.
STRESS ECHO
For patients with signs of ischemia and cardiac dysfunction
MRI
Delineates the transmural extent of MI
Distinguishes bet. reversible and irreversible myocardial ischemic injury
Useful in the assessment of patients with myocardial scarring and
ventricular aneurysms when ventricular remodelling surgery is an
option
Use of gadolinium can enhance scar tissue and are very useful in
viability assessment
Figure 3. Parasternal Short Axis view (top left); Parasternal Short Axis view at
the level of the aortic valve (top right); Parasternal Short Axis view at the
level of the papillary muscles. It is used to check for weakness of the
myocardium, as well as thickening or thinning of the cardiac muscle walls
(bottom)
3.
CARDIAC CATHETERIZATION
Measures intercardiac pressures and cardiac output
Localizes and quantifies intercardiac shunts
Determines internal cardiac anatomy and ventricular wall motion by
cineradiography
Determines coronary anatomy by coronary angiography
o Coronary angiography = primary diagnostic procedure for
determining degree of coronary artery disease
CT CORONARY ANGIOGRAPHY
Less invasive imaging of coronary anatomy
Extremely sensitive in detecting coronary stenosis
CORONARY ARTERY DISEASE (CAD)
Multifactorial disease in which the primary etiology is atherosclerosis.
Risk factors include hyperlipidemia, smoking, diabetes, hypertension,
obesity, sedentary lifestyle, male gender, and elevated levels of Creactive protein, lipoprotein A, and homocysteine.
Most important factor in long term treatment is the modification of
risk factors such as immediate cessation of smoking, control of
hypertension, weight loss, and reduction of serum cholesterol.
Myocardial ischemia from CAD may result in angina pectoris, MI, CHF,
cardiac arrhythmias, and sudden death.
Angina pectoris (periodic substernal chest pain that typically appears
with exertion and may radiate to the left upper extremity) is the most
common manifestation.
Page 2 of 15
SURGERY 4.3A
Myocardial infarction is a serious consequence of CAD occurring when
ischemia results in myocardial necrosis.
CORONARY ANATOMY
HEART
Base lies opposite the middle thoracic vertebra
th
Apex at 5 intercostal space, 10 cm from the midline
Measures 12 cm in length, 8 cm in width, and 6 cm in thickness
Weighs 280 grams
SURGERY 4.3A
Thallium Scan
PET Scan
MRI
REVASCULARIZATION
Prolong life and reduce major cardiovascular events
Improve the quality of life and functional status
o Decrease the possibility of a heart attack in the future
o Symptoms like chest pain will disappear in 80-90% of cases
*Refer to appendix for guidelines for revascularization w/ percutaneous
coronary intervention & coronary artery bypass grafting in patients
w/angina
OPERATIVE TECHNIQUES
Bypass Conduit Selection
o The most important criterion in conduit selection is graft patency.
SURGERY 4.3A
o
ETIOLOGY
o Rheumatic Heart Disease/Rheumatic fever (60% of cases of
acquired mitral stenosis)
o Other causes:
Mucopolysaccharidosis
CLASSIFICATION
o Normal Mitral Valve Area: 4 -6 cm2(Schwartz 4-5 cm2)
o Mild MS: 1.6 2.5 cm2
Begin experiencing symptoms upon exertion
o Moderate MS: 1 1.5 cm2
Symptoms may begin at rest
2
o Severe MS: <1 cm
Any physical exertion is typically limited
o NOTE:
1 cm2 is the critical point such that less than this, surgery is
already needed in which the patient requires valve repair or
replacement.
When the valve area is reduced to <2.5 cm2, patients may
begin to experience symptoms when the transmitral gradient
is exacerbated by conditions that either increase transmitral
flow or decrease diastolic filling time.
Symptoms may begin to occur at rest with the onset of
moderate stenosis.
Any physical exertion is typically limited by the time the MV
area is <0.8 to 1.0 cm2
CLINICAL MANIFESTATIONS
o First clinical signs of MS and are associated with pulmonary
venous congestion
Exertional dyspnea
Orthopnea
SURGERY 4.3A
o
Hepatomegaly
Ascites
Ankle edema
o Auscultatory triad: best heard at the apex
Calcification
Pulmonary congestion
MOBILITY
Highly
mobile
valve
with
leaflet tips only
restricted
Valve continues
to move forward
in
diastole,
mainly from the
base
No or minimal
forward
movement
of
leaflets
in
diastole
LEAFLET
THICKENING
Leaflets near
normal
in
thickness (45mm)
Mid leaflets
normal,
marked
thickening of
margins
(58mm)
Thickening
extended
through entire
leaflet
(58mm)
Marked
thickening of
all
leaflets
tissue (>8mm)
SUBVALVAR
THICKENING
Minimal
thickening just
below the mitral
leaflets
Thickening
of
chordal
structures
extending up to
1/3 of chordal
length
CALCIFICATION
A single area of
increased echo
brightness
Scattered areas
of
brightness
confined
to
leaflet margins
Thickening
extended to the
D/3
of
the
chords
Brightness
extended
into
the mid portion
of the leaflets
Extensive
thickening
&
shortening of all
chordal
structures
extending down
to
papillary
muscles
Extensive
brightness
throughout
much of leaflet
tissue
MITRAL REGURGITATION/INSUFFICIENCY
ETIOLOGY:
o Myxomatous degeneration
o Rheumatic Fever
o Ischemic heart disease
o Infective Endocarditis
o Congenital abnormalities
o Dilated Cardiomyopathy
o Others: Trauma, collagen vascular diseases, previous chest
radiation, hypereosinophilic syndrome, carcinoid disease and
exposure to certain drugs.
CARPENTIER FUNCTIONAL CLASSIFICATION:
Focuses on the functional anatomic and physiologic characteristics
of the MV pathology, and proposes three basic types of diseased
valves based on the motion of the free edge of the leaflet relative
to the plane of the mitral annulus.
Table 2. Carpentier Functional Classification
Annular dilatation or leaflet perforation with normal
Type I
leaflet motion
Leaflet prolapsed or ruptured chordae tendinae with
Type II
increased leaflet motion, typically occurring in patients
with degenerative disease
Restricted leaflet motion with leaflets not reaching the
Type III
proper plane of closure during systole; occurs in (a)
rheumatic patients and (b) chronic ischemic insufficiency
PATHOPHYSIOLOGY:
Basic pathophysiologic abnormality: retrograde flow of the
portion of the LV stroke volume into the left atrium during systole
due to an incompetent MV or dilated MV annulus.
Acute severe MR can result from ruptured chordae tendineae,
papillary muscle, or infective endocarditis, and causes a sudden
volume overload on both the left atrium and ventricle.
Chronic MR has indolent course, with increasing volume overload
of the left atrium and ventricle as the effective valve orifice size
becomes larger.
SURGERY 4.3A
Replacement
+ CABG
LESIONS IN THE MITRAL VALVE
COMMISSUROTOMY
o Open mitral commissurotomy permits direct and careful
examination of mitral valve and chordate tendinae, removal of
atrial thrombus, division of fused commissures and leaflets,
mobilized scarred chordate tendinae, debride calcifications,
correct pre-existent mitral regurgitation.
PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY (PBMV)
o The balloon is introduced via the femoral vein and then inserted
across the mitral valve, breaking the mitral valve leaflets.
o Not a very accurate procedure; can only increase the mitral valve
orifice
o Done in patients who are not good candidates for surgical
procedures (can serve as a bridge to the definitive surgery)
o May be done for uncomplicated mitral stenosis.
o Increases the mitral valve area to approximately 2 cm2 to
significantly cause decline in the left atrial pressure and
transvalvular gradient.
MITRAL VALVE REPAIR
On opening the atrium, the endocardium is examined for a jet
lesion, a roughened area caused by a regurgitant jet striking the
wall.
o Anterior Leaflet Procedures
The anterior leaflet may be repaired via chordal shortening,
chordal transposition, artificial chordal replacement, and
triangular resection of the anterior leaflet.
LESION
Fused, thickened, calcified, redundant
Elongated, shortened, ruptured,
Fused
Dilated, calcified
SURGERY 4.3A
Edge-to-edge Repair
Da Vinci Robot
Tricuspid autographs
o Advantages over MV Replacement:
Preservation of the patients native valve & subvalvular
apparatus
Age
Page 8 of 15
SURGERY 4.3A
Autograft
o The diseased aortic valve is replaced using the patients native
pulmonary valve graft as an autograft. (Ross Procedure)
o Particularly beneficial in children
ETIOLOGY:
o Acquired/Degenerative Calcific Disease most common, affecting
older patients particularly >70 years old 50%
o Bicuspid Aortic Valve 30%
o Rheumatic Disease common in developing countries 10-15%
PATHOPHYSIOLOGY:
CLINICAL MANIFESTATIONS:
o Exertional dyspnea classic symptom including angina and
syncope[4]
o Decreased exercise capacity (NYHA Functional Classification II or
III)
o Heart failure
o Angina
Due to the increased oxygen demand of the hypertrophied
myocardium in the setting of reduced oxygen supply
secondary to coronary compression
o Syncope
Most common during exertion, as systemic vasodilation in
the setting of a fixed cardiac output causes decreased
cerebral perfusion. It may also occur at rest secondary to
paroxysmal atrial fibrillation and subsequent loss of atrial
booster pump function.
o Harsh basal crescendo-decrescendo (diamond-shaped) systolic
nd
murmur at R 2 ICS with radiation to carotid arteries
o Diminished and delayed peripheral pulse (pulsus parvus et tardus)
Narrow and sustained peripheral pulse
o S4 gallop at apex with development of left ventricular
hypertrophy)
Page 9 of 15
SURGERY 4.3A
Operative Risk: 1 5 %
Age
Cerebrovascular
Diabetes Mellitus
Infective Endocarditis
Renal Failure
Prior
cardiac
Hypertension
operation
Myocardial Infarction
Peripheral
Vascular
Cardiogenic Shock
Disease
NYHA
Functional
Classification
o NOTE: Check risk factors of the patient, note gradient and PA
lower risk 3% and high risk 7-10%
AORTIC REGURGITATION/INSUFFICIENCY
ETIOLOGY:
o May result from disease of the valve leaflets or of the aortic root
due to:
Degenerative
Congenital Disease
Inflammation
Aortoannular Ectasia
Infectious
disease
Aneurysm of aortic
(Endocarditis, Rheumatic
root
Fever)
Aortic dissection
PATHOPHYSIOLOGY:
Basic pathophysiologic abnormality: retrograde flow of a portion
of the LV stroke volume into the left ventricle during diastole,
producing left ventricular volume overload.
Page 10 of 15
SURGERY 4.3A
Left ventricular
volume
overload/
increased
preload
Increased left
ventricular
strokevolume
during systole
Left ventricular
dilatation
Decreased coronary
perfusion,
increased oxygen
demand
Widened pulse
pressure, low
diastolic pressure
"Afterload mismatch"
and progressive systolic
dysfunction
Blood
regurgitation
into left
ventricle in
diastole
Left ventricular
failure, pulmonary
hypertension
CLINICAL MANIFESTATIONS:
o Asymptomatic
o Dyspnea on exertion
o Decreased exercise capacity
o Palpitations
o Left ventricular heave
o High-pitched decrescendo diastolic blowing murmur 3rd left ICS
sternal border
DIAGNOSTICS:
o Chest X-ray cardiomegaly
o Electrocardiogram (ECG) normal, LVH, sinus rhythm, atrial
fibrillation
o 2D Echo primary diagnostic tool to evaluate chamber size, left
ventricular function, degree of insufficiency
TREATMENT:
o Aortic valve replacement
Procedure:
Aortotomy is performed, extending medially from
approximately 1 to 2 cm above the right coronary artery
and inferiorly into the noncoronary sinus, and the valve
is completely excised.
The annulus is thoroughly debrided of calcium deposits.
After the calcium has been removed, the ventricle is
copiously irrigated with saline. Annulus is sized and an
appropriate prosthesis is selected.
Pledgeted horizontal mattress sutures are then placed
into the aortic valve annulus and subsequently throught
the sewing ring of the prosthetic valve, taking care to
avoid damage to the coronary ostia, the conduction
system, and the MV apparatus.
o Aortic valve repair
The aneurysmal portion of the aortic root is excised, and the
aortic valve is reimplanted inside a tubular Dacron graft, with
concomitant reimplantation of the coronary arteries.
SURGERY 4.3A
1.
2.
3.
4.
5.
Page 12 of 15
Surgery 4.3a
Dr. Villanueva
November 10, 2014
C.B.
56 y/o male
Taxi driver
Imus, Cavite
CC: DYSPNEA
September 2011
(-) Chest pain
(+) Dyspnea on less than
ordinary
activities;
orthopnea; PND; bipedal
pitting edema
March 2012
(+) Palpitations and respiratory
distress
Admitted
Given Lanoxin and diuretics
incorporated into his chelation
medications
Decided to seek consult at PHC
REVIEW OF SYSTEMS
General: weight loss, loss of appetite
SHEENT: no rash, no visual dysfunction, no redness, no deafness, no
tinnitus, no discharge, no epistaxis, no postnasal drip, no bleeding
gums, no sores
Respiratory: no cough, no hemoptysis, dyspnea on minimal exertion
Gastrointestinal: no nausea, no vomiting, no abdominal pain, no
diarrhea, no hematemesis, no hematochezia, no melena
Genitourinary: no flank pain, no urinary frequency, no hesitancy, no
dysuria, no hematuria
Endocrine: no polyuria, no polydipsia, no polyphagia
Hematologic: no bleeding episodes
Neurologic: no headache, no seizure, no mental changes
Psychiatric: no anxiety, no depression
PAST MEDICAL HISTORY
(+) HPN
(+) DM (2009)
o Metformin 500 mg/tab BID
(-) Asthma/allergy
SALIENT FEATURES
SUBJECTIVE
OBJECTIVE
56 y/o male
2D echo result of MSWA with
depressed EF of 46%
Chest pain and dyspnea on
minimal exertion
Soft S1 at the apex; (+) S3
Orthopnea and PND
2/6 holosystolic murmur at the
apex
Palpitation
Edema
DM
History of previous ACS (Dec
2005, Dec 2010, Apr 2011,
Jun 2011)
60 pack year smoker
Family history of premature
CAD
CLINICAL IMPRESSION
Cardiac Diagnosis:
o Etiology: HCVD
o Anatomic: CAD
o Physiologic: CSA s/p AMI (Dec 2005, Dec 2010, Apr 2011, Jun
2011); functional mitral regurgitation
o Functional: NYHA Class III, CCS III
Other Diagnosis:
o Type II Diabetes Mellitus, controlled
Page 13 of 15
Surgery 4.3a
Dr. Villanueva
November 10, 2014
Page 14 of 15
Surgery 4.3a
Dr. Villanueva
November 10, 2014
Page 15 of 15