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Lorne H. Blackbourne-Surgical recall, Sixth Edition 2011.pdf

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660 Section III / Subspecialty Surgery
What are the signs/	Murmur (new or changing)
symptoms?	Petechiae
	Splinter hemorrhage (ﬁngernails)
	Roth spots (on retina)
	Osler nodes (raised, painful on soles and
	palms; Osler Ouch!)
	Janeway lesions (similar to Osler nodes,
	but ﬂat and painless) (JaneWAY
	pain aWAY)
Which diagnostic tests	Echocardiogram, TEE
should be performed?	Serial blood cultures (deﬁnitive)
What is the treatment?	Prolonged IV therapy with bactericidal
	antibiotics, to which infecting
	organisms are sensitive
What is the prognosis?	Infection can progress, requiring valve
	replacement

CONGENITAL HEART DISEASE

VENTRICULAR SEPTAL DEFECT (VSD)

What is its claim to fame? Most common congenital heart defect

What is it?	Failure of ventricular septum to
	completely close; 80% of cases involve
	the membranous portion of the
	septum, resulting in left-to-right shunt,
	increased pulmonary blood ﬂow, and CHF
	if pulmonary to systemic ﬂow is 2:1
What is pulmonary vascular	Pulmonary artery hyperplasia from
obstructive disease?	increased pulmonary pressure caused by
	a left to right shunt (e.g., VSD)
What is Eisenmenger’s	Irreversible pulmonary HTN from chronic
syndrome?	changes in pulmonary arterioles and
	increased right heart pressures; cyanosis
	develops when the shunt reverses
	(becomes right to left across the VSD)

What is the treatment of Eisenmenger’s syndrome?

Only option is heart-lung transplant; otherwise, the disease is untreatable

Chapter 72 / Cardiovascular Surgery 661

What is the incidence of VSD?

30% of heart defects (most common defect)

PATENT DUCTUS ARTERIOSUS (PDA)

What is it?	Physiologic right-to-left shunt in fetal
	circulation connecting the pulmonary
	artery to the aorta bypassing fetal lungs;
	often, this shunt persists in the neonate
What are the factors	Hypoxia, increased prostaglandins,
preventing closure?	prematurity
What are the symptoms?	Often asymptomatic
	Poor feeding
	Respiratory distress
	CHF with respiratory infections
What are the signs?	Acyanotic, unless other cardiac lesions
	are present; continuous “machinery”
	murmur
Which diagnostic tests	Physical examination
should be performed?	Echocardiogram (to rule out associated
	defects)
	Catheter (seldom required)
What is the medical	Indomethacin is an NSAID:
treatment?	prostaglandin (PG) inhibitor (PG keeps
	PDA open)
What is the surgical	Surgical ligation or cardiac
treatment?	catheterization closure at 6 months to
	2 years of age
TETRALOGY OF FALLOT (TOF)

What is it?	Misalignment of the infundibular septum
	in early development, leading to the
	characteristic tetrad:
	1. Pulmonary stenosis/obstruction of
	right ventricular outﬂow
	2. Overriding aorta
	3. Right ventricular hypertrophy
	4. VSD

662 Section III / Subspecialty Surgery
What are the symptoms?	Hypoxic spells (squatting behavior
	increases SVR and increases pulmonary
	blood ﬂow)
What are the signs?	Cyanosis
	Clubbing
	Murmur: SEM at left third intercostal
		space
Which diagnostic tests	CXR: small, “boot-shaped” heart and
should be performed?		decreased pulmonary blood ﬂow
	Echocardiography
What is the prognosis?	95% survival at specialized centers
IHSS

What is IHSS?	Idiopathic Hypertrophic Subaortic
	Stenosis
What is it?	Aortic outﬂow obstruction from septal
	tissue
What is the usual	Similar to aortic stenosis
presentation?
COARCTATION OF THE AORTA

What is it?	Narrowing of the thoracic aorta, with or
	without intraluminal “shelf” (infolding of
	the media); usually found near ductus/
	ligamentum arteriosum
What are the three types?	1.	Preductal (fatal in infancy if untreated)
	2.	Juxtaductal
	3.	Postductal
What percentage are	60% (bicuspid aortic valve is most
associated with other	common)
cardiac defects?
What is the major route of	Subclavian artery to the IMA to the
collateral circulation?	intercostals to the descending aorta
What are the risk factors?	Turner’s syndrome, male female

	Chapter 72 / Cardiovascular Surgery 663
What are the symptoms?	Headache
	Epistaxis
	Lower extremity fatigue S claudication
What are the signs?	Pulses: decreased lower extremity pulses
	Murmurs:
	1. Systolic—from turbulence across
	coarctation, often radiating to infra-
	scapular region
	2. Continuous—from dilated collaterals
Which diagnostic tests	CXR: “3” sign is aortic knob, coarctation,
should be performed?	and dilated poststenotic aorta; rib
	notching is bony erosion from dilated
	intercostal collaterals
	Echocardiogram
	Cardiac catheterization if cardiac defects
What is the treatment?	Surgery:
	Resection with end-to-end anastomosis
	Subclavian artery ﬂap
	Patch graft (rare)
	Interposition graft
	Endovascular repair an option in adults
What are the indications for	Symptomatic patient
surgery?	Asymptomatic patient 3 to 4 years
What are the possible	Paraplegia
postoperative complications?	“Paradoxic” HTN
	Mesenteric necrotizing panarteritis (GI
	bleeding), Horner’s syndrome, injury
	to recurrent laryngeal nerve
What are the long-term	Aortic dissection, HTN
concerns?
TRANSPOSITION OF THE GREAT VESSELS

What is it?	Aorta originates from the right ventricle
	and the pulmonary artery from the left
	ventricle; fatal without PDA, ASD, or
	VSD—to allow communication between
	the left and right circulations

664 Section III / Subspecialty Surgery
What is the incidence?	From 5% to 8% of defects
What are the signs/	Most common lesion that presents with
symptoms?	cyanosis and CHF in neonatal period
	( 90% by day 1)
Which diagnostic tests	CXR: “egg-shaped” heart contour
should be performed?	Catheterization (deﬁnitive)
What is the treatment?	Arterial switch operation—aorta and
	pulmonary artery are moved to the correct
	ventricle and the coronaries are reimplanted
EBSTEIN’S ANOMALY

What is it?	Tricuspid valve is placed abnormally low
	in the right ventricle, forming a large
	right atrium and a small right ventricle,
	leading to tricuspid regurgitation and
	decreased right ventricular output
What are the signs/symptoms?	Cyanosis
What are the risk factors?	400 the risk if the mother has taken
	lithium
VASCULAR RINGS

What are they?	Many types; represent an anomalous devel-
	opment of the aorta/pulmonary artery from
	the embryonic aortic arch that surrounds
	and obstructs the trachea/esophagus
How are they diagnosed?	Barium swallow, MRI
What are the signs/	Most prominent is stridor from tracheal
symptoms?	compression
CYANOTIC HEART DISEASE

What are the causes?	Five “Ts” of cyanotic heart disease:
	Tetralogy of Fallot
	Truncus arteriosus
	Totally anomalous pulmonary venous
	return (TAPVR)
	Tricuspid atresia
	Transposition of the great vessels

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