Intraoperative Heart Failure

In the operating room, to differentiate left heart failure from right heart failure, one may be able to get some idea simply by looking at the heart. If the right ventricle appears to be sluggish and the left ventricle is contracting normally, the answer may be clearly visible and vice versa. Hemodynamic parameters can also give us some idea whether there is right heart failure versus left heart failure. If there are high pulmonary artery pressures and high CVP, (i.e. elevated right heart...

Aortic Rupture

Injuries identified in the secondary survey require a further, indepth physical examination, upright chest film, arterial blood gas and EKG. Traumatic rupture of the aorta most commonly occurs just distal to the ligamentum arteriosum in the proximal descending thoracic aorta. It may range from a small intimal tear of the aorta to a full-blown complete transection with either exsanguinating hemorrhage or preservation of the patient's life by a column of peri-adventitial connective tissue,...

Fluid management

The objectives of postoperative fluid management are 1) to maintain an adequate intravascular volume 2) to reduce the excessive interstitial fluid overload 3) to prevent congestive heart failure and subsequent pulmonary edema. We are able to evaluate the postoperative fluid balance of an individual patient 1) obtaining accurate central venous pressure, pulmonary capillary wedge pressure, pulmonary diastolic pressure 2) assessing the adequacy of cardiac output 3) evaluating the patient input...

Info

Cardiopulmonary bypass foreign circuit. Hageman factor 12 activates four pathways 1) fibrinolysis 2) the clotting cascade such that even in the presence of heparin consumption of coagulation factors occurs to some degree 3) the complement cascade including C3A and C5A resulting in increased vascular permeability, third spacing, and neutrophil migration 4) the kallikrein bradykinin system resulting in increased vascular permeability and pain. Cardiopulmonary bypass is a stress on the body...

Esophagomyotomy

This can be successfully performed thoracoscopically although it is the most difficult and technically challenging procedure thus described. A truncal vago-tomy may also be performed thoracoscopically using similar techniques. The critical concept is that the esophagus must be accurately and easily identified. This is best accomplished by insertion of an upper GI flexible endoscope to permit more rapid visualization of the esophagus thoracoscopically. We have used an esophagoscope with a...

Radionuclide Imaging

Nuclear cardiac imaging procedures are noninvasive techniques that provide valuable information for cardiac disease in two main broad categories. The first category involves the assessment of ventricular function by radioactive tracers that remain in the intravascular space during the study. The second category of imaging visualizes myocardial intracellular uptake of radioactive tracers reflecting myocardial perfusion, metabolism and viability. The multigated equilibrium blood pool imaging...

Superior Sulcus Tumors

Superior sulcus tumors are a special type of lung carcinoma invading the chest wall. This is usually a low grade squamous cell carcinoma arising at the apex of the upper lobes which invades the endothoracic fascia, and may involve the lower roots of the brachial plexus, the sympathetic chain, and adjacent ribs and often vertebral bodies (Fig. 12.3a-d). The history and physical examination are important, since these patients frequently develop characteristic pain in the shoulder, radiating down...

Of The Esophagus

After it is established that the patient is a surgical candidate and that the tumor is resectable, there are several surgical procedures that can be successfully used. It is important to note that tumors of the gastric cardia can be included in the category of malignant tumors of the lower third of the esophagus. These tumors are usually adenocarcinomas, whereas most tumors of the esophagus are squamous cell carcinomas. Resection of malignant tumors of the lower esophagus consists of...

N

Nasogastric (NG) tube 152, 154, 162 Needle biopsy lung mass 221 Neo-Synephrine 156 Neuroblastoma 245 Neurofibroma 245 Neurolemmoma 245 Nifedipine 61, 62, 158 Nipride 32 Nissen fundoplication 236-238 Nitroglycerin 32, 62, 63 Nitroprusside 156, 158, 159 Nodal rhythm 160 Nonsmall cell lung cancer metastasis 193, 219, 221 Nonsmall cell lung cancer (NSCLC) 182, 191, 193 chest wall involvement 183, 185, Off-pump coronary artery bypass (OPCAB) 141-144 Omniscience 98 Osteochondroma 219 Osteosarcoma...

Pulmonary Contusion

The main problem that occurs with pylmonary contusion is inadequate ventilation from injured parenchyma. Severe pulmonary contusion should be man- Fig 19.10. Bronchogram of a patient sustaining a left mainstem bronchial tear. The injury was initially missed on flexible bronchoscopy. Bronchography revealed occlusion of the left lower lobe bronchus. Subsequent bronchoscopy confirmed a spiral tear in the left mainstem bronchus occluding the lower lobe orifice. aged with endotracheal intubation and...

Nonsmall Cell Lung Cancer

Carcinoma of the lung is the most common cause of death due to cancer in both men and women. Lung cancer can be divided into two fundamental types small cell lung cancer (which is synonymous with oat cell lung cancer) and nonsmall cell lung carcinoma. The differentiation is clinically important as small cell lung carcinoma has a much lower survival rate than nonsmall cell carcinoma. The histologic subtypes of nonsmall cell lung carcinoma include adenocarcinoma, large cell carcinoma and squamous...

Thoracic Anesthesia

Surgical interventions which involve thoracotomy and lateral positioning of the patient generally require that the ipsilateral lung remain deflated to optimize exposure. One lung ventilation is accomplished by the use of a double lumen tube (DLT) which consists of an endobronchial tube as well as a tube which remains in the trachea. Each tube is cuffed. Right and left DLTs are designed so that the endobronchial tube enters the right or left bronchus, respectively. It is essential that the...

Cardiac Catheterization

Diagnostic coronary angiography is the standard of reference for determining the severity of stenosis resulting from atherosclerosis in the coronary arteries. Visualization of the lumen of the coronary artery to assess for the need for vascularization is performed by injection of iodinated contrast directly into the coronary arteries. Since the contrast resolution is limited with fluoroscopy (the imaging method used during angiography), direct enhancement of the blood pool in the artery of...

T3 Chest Wall Involvement

Chest wall invasion by lung carcinoma occurs in approximately 5 with a 5 year post-resection survival rate of approximately 1 in 3 when regional lymph nodes are negative. There is general agreement that full thickness chest wall resection is indicated in patients with nonsmall cell lung cancer invading the chest wall. There is some disagreement if the tumor extension appears to involve only the parietal pleura. Some feel that an extrapleural dissection should be attempted and if a plane is...

R

Lung cancer 185, 187, 190, 191, 193 Radionuclide imaging 11 Recurrent laryngeal nerve lung cancer 183 Renal failure 162-164 treatment 154, 163 Rhabdomyosarcoma 219 Right atrium anatomy 1, 4, 5 Right bundle branch 4 Right bundle branch block (RBBB) 149 anatomy 1, 2, 4, 7 Right ventricular pressure 92, 147 Roos test 271, 273 Ross procedure 104, 107 RVAD (right ventricular assist device) 31, 63 Schwannoma 245, 246 Segmentectomy 189, 190, 204-206 Sepsis 150, 156, 168 Sequestration 265, 266 Shock...

Cancer Staging And Lymph Node Biopsy

Using video thoracoscopy, cancer staging can be accomplished by visual inspection of the pleural space. If the pleura is studded with tumor, a diagnosis of stage IV lung carcinoma can be made and the patient can be considered unresectable. Lymph node biopsies can be performed in locations such as the aortopulmonary window or subcarinal regions, as well as hilar and tracheobron-chial areas. This approach, in addition to the grasper and scissors on either side of the camera, utilizes a retractor...

Colonicjejunal Esophageal Replacement

Once it is established that esophageal resection is indicated, an organ for esophageal replacement becomes necessary. Although the stomach is the usual organ for esophageal replacement, the colon or jejunum also can be used. The stomach, in general, is sturdier and has more reliable blood supply. Care must be taken that the replacement organ is usable and that it is pathologically free of disease. Endoscopy, arteriography and contrast radiography are useful to determine this. Not all of these...

Bibliography

Anesthesia for thoracic surgery. In Miller ed. Anesthesia, New York Churchill Livingstone 1994 1689-1700. 2 Birman H, Haq A et al. Continuous monitoring of mixed venous oxygen saturation in hemodynamically unstable patients. Chest 1985 85(5) 753-756. 3 Dhainaut JF, Brunet F et al. Bedside evaluation of right ventricular performance using a rapid thermodilution method. Critical Care Medicine 1987 15(2) 148-152. 4 Hunger J. Drug therapy new neuromuscular blocking drugs. New...

Thoracic Aortic Aneurysms

General Classification and Principles Thoracic aneurysms are most commonly located in the ascending and descending thoracic regions (Fig. 7.10). The more difficult transverse arch and thoracoabdominal locations are also less common. Several etiologies exist for chronic aortic aneurysms. The most common cause is atherosclerotic degeneration of the aorta (Fig. 7.11a-d), usually occurring in elderly smokers. Chronic aortic dissection (Fig. 7.12a-c), Marfan's syndrome (Fig. 7.13a-c), cystic medial...

Anterior Mediastinum

Anterior mediastinal tumors may consist of thyroid enlargement for the superior portion of the anterior mediastinum. This usually involves a thyroid goiter, but may involve a thyroid tumor. Thymomas are the most common anterior mediastinal mass. They are usually benign but may be malignant. The interrelationship between thymomas and myasthenia gravis will be discussed subsequently, suffice it to say that 10 of patients with myasthenia gravis have thymomas, whereas half of patients with thymomas...

The Approach To The Patient With A Lung Mass

The patient who presents with the chest x-ray finding of lung mass must be evaluated to quickly and accurately determine the etiology of the lesion and establish a treatment plan. The history and physical examination are of prime importance. The patient is asked about symptoms of cough, sputum production, chest pain, shortness of breath and weight loss. Hemoptysis is an important finding. A previous history of tuberculosis should be elicited. Physical examination should include cardiopulmonary...

Hypertension

Generally we like to keep our patient's systolic blood pressures below 120-130 mmHg. Blood pressures above this level for the average cardiac patient are excessively high. It is not uncommon for a patient who is not bleeding postop-eratively to suddenly start bleeding from suture lines when the blood pressures are elevated. In addition, the work required by the recovering postoperative heart is markedly increased when systolic hypertension occurs. The causes of postoperative hypertension are...

Myasthenia Gravis And Thymoma

Myasthenia gravis is a condition in which the patient develops progressive muscle weakness secondary to acetylcholine receptor antibodies. Medications used to treat myasthenia gravis include anti-cholinesterase medications which block the cholinesterase-mediated removal of the acetylcholine from its receptor. The classifications of myasthenia gravis include ocular and generalized. In the ocular group, there is involvement of ocular muscles only with ptosis and diplopia. This is a very mild form...

Postcoarctation repair

It is well known that post-coarctation repair individuals frequently develop a severe hypertensive response. This may be accompanied by abdominal ischemia as well as disruption of various suture lines. Therefore, frequent examinations of the abdomen as well as the institution of Nitroprusside and or Esmolol to control the paradoxical hypertension should be initiated. The hypertension associated with this disease state may be prolonged and these patients may need to be switched to oral...

Coronary Artery Disease

Angina Pectoris With Pph And Cpd

Baumgartner and Matthew Budoff The patient who presents with chest pain needs to be thoroughly evaluated. A complete history and physcial is first undertaken, taking special care to note the presence of cardiac risk factors history of premature family history of CAD, hypertension, diabetes, obesity, hypercholesterolemia and smoking. A physical examination should focus on the cardiovascular system, followed by laboratory assessment of cardiac enzymes (troponin, CPK and MB), a chest...

Thoracotomy For Obtuse Marginal Opcab

Obtuse Marginal Artery

Reoperative coronary surgery in patients with patent IMA grafts may be hazardous. If such a patient only requires grafting of the circumflex system, a thoracotomy approach with single-lung ventilation may be useful to avoid cardiac injury from sternal reentry. This thoracotomy approach usually 4th interspace may be combined with OPCAB instrumentation to provide local stabilization for obtuse marginal grafting Fig 9.6 . The proximal anastomosis should be done to the descending thoracic aorta or,...

Mitral Valve Replacement Chordal Preservation

Mitral Valve Commissurotomy

Standard mitral exposure. Left atriotomy begins just anterior to right superior pulmonary vein. This affords excellent exposure of the mitral valve in most cases. Fig. 6.7b. Dubost mitral exposure. A bi-atrial, transseptal incision is made going through the interatrial septum at the fossa ovalis. Bicaval can-nulation and snares are required. the intra-annular position of the valve prevents the cordae and annulus from impinging on the leaflets of the mechanical...

Valvular Heart Disease

Intercoronary Commissure

The aortic valve is a tricuspid valve with a right, left and noncoronary cusp Fig. 6.1 . The right coronary orifice is in the sinus of Valsalva of the right coronary cusp the left main coronary ostium is in the sinus of Valsalva of the left coronary cusp. The junction between the left and right coronary cusps is the intercoronary commissure the junction between the right coronary cusp and the noncoronary cusp is the anterior commissure the junction between the noncoronary cusp and the left...

Cardiac Tumors

Malignant Neurogenic Tumors

Myxomas are the most common benign tumors of the heart. They are usually globular in shape and have a soft, gelatinous consistency. They have a predilection for the left atrium where they are attached to the limbus of the fossa ovalis. Myxomas occur in patients of all age groups but are most frequent in middle-aged women. Seventy-five percent of myxomas originate in the left atrium, 18 in the right atrium and the remainder in the ventricles. Patients present either with signs and symptoms of...

Hiatal Hernia And Gastroesophageal Reflux

Diaphragm Crura

The overall management of patients who present with dysphagia or heartburn must include, of course, a cardiovascular history and examination since the suspicion of ischemic cardiac disease or other myocardial dysfunction must always be in mind. The esophageal problems that may result in dysphagia or heartburn can include carcinoma, gastroesophageal reflux or motility disorders including achalasia or diffuse esophageal spasm . The preoperative evaluation of patients who present with suspected...

Chest Wall Tumors

Sarcome Costochondral

The tumors of the chest wall fall into several classifications. They may be of bony or soft tissue origin. They may be benign or malignant and those that are malignant may be primary or metastatic. They may be lesions that invade the chest wall from the lung, pleura, mediastinum or breast. Benign rib tumors include osteochondroma, chondroma, fibrous dysplasia and histiocytosis X. Malignant rib tumors include multiple myeloma, osteosarcoma, chondrosarcoma and Ewing's sarcoma. Osteochondroma is...

The Bronchial Tree

Intermedius Bronchus Lingular

The trachea bifurcates at about the level of the fourth thoracic vertebra into the right and left mainstem bronchi. The tracheal bifurcation at the carina is considered a major anatomical landmark where several anatomic events occur. These include the origin of the great vessels coming off the aorta and the entry of the Fig 11.1a. Surface anatomy of the lungs, viewed anteriorly. Fig 11.1a. Surface anatomy of the lungs, viewed anteriorly. Fig 11.1b. PA and lateral x-rays of a normal chest and...

Anatomy

Deep Cervical Fascia

The esophagus is a continuation of the pharynx and ends at the cardia of the stomach. The transition from pharynx to esophagus is at the lower border at the 6th cervical vertebra which corresponds to the cricoid cartilage anteriorly. The esophagus deviates to the left in the lower portion of the neck, then returns to the midline in the mid-portion of the thorax near the bifurcation of the trachea. In the lower portion of the thorax the esophagus again deviates to the left to pass the...

Opcab

Deep Pericardial Sutures Cabg

The MIDCAB technique does not address circumflex disease which is not easily accessible with a limited thoracotomy, and is, therefore, applicable to only a minority of CABG patients requiring complete surgical revascularization. Offpump coronary artery bypass OPCAB refers to complete surgical coronary revascularization without the heart-lung machine. It is generally done via median sternotomy in order to approach the anterior surface of the heart as well as the less readily accessible areas...

Venovenous Bypass

Cannulas For Venoveno Bypass

Another extracorporeal technique used in certain special situations is venovenous bypass VVB . It is used predominantly for vascular isolation of difficult inferior vena cava procedures. VVB was originally described for the anhepatic phase of liver transplantation. Other uses include the resection of renal and adrenal tumors with caval involvement and trauma to the retrohepatic inferior vena cava. VVB drains blood from the lower half of the body via a centrifugal pump into the central venous...

Left Atrialfemoral Bypass

Fem Fem Bypass Subcutaneous Fat

Left atrial femoral bypass is partial bypass in which there is no oxygenator involved. Left atrial flow is transmitted through a centrifugal pump to the femoral artery Fig. 3.4 . It is used in conditions where there is a need for spinal protection below the level of the cross-clamp, and this may include descending thoracic and thoracoabdominal operations in a similar way that femoral-femoral bypass is utilized.

Aortic Aneurysm Dissections Ruptures

Classification Aortic Dissection

The topic of aortic aneurysms, dissections and ruptures is a difficult one in terms of the classification and management. First, the common misconception that the thoracic aortic aneurysm is the same as a dissection should be dispelled. These are different entities and their management is different with one exception. When an aortic dissection has persisted for a long period of time, it becomes a chronic aortic dissection which should actually be classified under the term chronic aortic...

Lymphatic System

Lymphatic System Mediastinal

The lymphatic system of the lung includes intrapulmonary lymph nodes N-1 and mediastinal lymph nodes N-2 . The intrapulmonary nodes are within the visceral pleural envelope. These are shown in Figure 11.6. The mediastinal lymph nodes are also shown in Figure 11.6. They can be classified numerically to include node stations 1, 2, 3, 4, 5, 6, 7, 8 and 9. It should be noted that level 10 nodes may be considered either intrapulmonary or mediastinal, depending on the level that they are sampled at....

Coronary Arteries

Posterolateral Ventricular Branch

These consist of a left main coronary artery which bifurcates to the circumflex coronary artery and left anterior descending coronary artery Fig. 1.4 . The orifice of the left main coronary artery lies in the left coronary sinus. The orifice of the right coronary artery arises from the right coronary sinus. The circumflex coronary artery lies in the groove between the left atrium and left ventricle adjacent to the coronary sinus. The circumflex coronary artery gives off obtuse marginal branches...

Technique

Antegrade Cardioplegia Cannula

In summary, cannulation and cardiopulmonary bypass is instituted by placing aortic pursestrings in the distal ascending aorta followed by venous pursestrings. The venous pursestring is either a single right atrial pursestring in the case of coronary bypass surgery or aortic valve replacement, or in the case of mitral valve replacement or tricuspid valve procedures, a separate superior vena cava and inferior vena cava pursestring. Figure 3.2 shows the cardiac cannulation sites for various...