Dissecting Aortic Aneurysm. Controversies
CONTROVERSIES
13. Which is preferred: surgical or medical management of descending dissections?
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* Initial surgical managementApproximately 25% of patients initially treated medically need an operation eventually.
* Operative mortality is much lower today (20%) than in the past.
* Medical management has the same in-hospital mortality (20%).
* Initial medical managementThis avoids unnecessary operation and its attendant cost and complication rate.
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Dissecting Aortic Aneurysm
81 DISSECTING AORTIC ANEURYSM
Laurence H. Brinckerhoff M.D., David N. Campbell M.D.
1. Why is the term dissecting aortic aneurysm really incorrect?
Show answer
The correct term should be dissecting aortic hematoma because the lesion is not an aneurysm. Blood dissects between the middle and outer layers of the media and adventitia of the aorta (specifically, there does not need to be an intimal tear, although there usually is).
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Solitary Pulmonary Nodule
80 SOLITARY PULMONARY NODULE
Jamie M. Brown M.D., Marvin Pomerantz M.D.
1. What is a solitary pulmonary nodule?
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A solitary pulmonary nodule or “coin lesion” is < 3 cm and is discrete on chest radiograph. It is usually surrounded by lung parenchyma.
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Lung Cancer
79 LUNG CANCER
Jamie M. Brown M.D.
1. How common is lung cancer?
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The incidence of lung cancer is approximately 180,000 new cases annually or 54.2 per 100,000 patients. More than 162,000 patients die annually, so the overall survival rate is 10%. This number has not improved over the past 35 years despite some treatment advances because of:
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Thoracic Surgery For Non-Neoplastic Disease. Empyema
EMPYEMA
10. What is an empyema, and what causes it?
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An empyema is a purulent (infected) effusion. Fluid or blood in the pleural space can be directly innoculated (with bugs) during surgery or trauma (33%) or by contamination from contiguous sites (50%) such as bronchopulmonary infection (most common). Most empyemas are parapneumonic, and the most commonly involved organisms are Staphylococcus aureus, enteric gram-negative bacilli, and anaerobes. Many times, infections are polymicrobial. Often there is no growth of an empyema culture because of effective antibiotic therapy or inadequate culture techniques, particularly with anaerobes.
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Thoracic Surgery For Non-Neoplastic Disease. Pleural Effusion
PLEURAL EFFUSION
6. What is a pleural effusion?
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Pleural fluid is generated in normal adults at a rate of 5-10 L per 24 hours in the combined hemithoraces, but normal adults have only 20 mL of pleural fluid present at any time. Pleural effusions develop when there is either increased production or decreased resorption. Pathologic conditions leading to effusions include increased capillary permeability (inflammation, tumor), increased hydrostatic pressure (e.g., in congestive heart failure [CHF]), decreased lymphatic drainage (tumor, radiation fibrosis), decreased oncotic pressure (hypoalbuminemia), or combinations of these.
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Thoracic Surgery For Non-Neoplastic Disease. Tuberculosis
TUBERCULOSIS
1. What are the clinical manifestations of pulmonary tuberculosis?
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They can be almost anything or nothing (it has been stated that if you know tuberculosis, you know all of medicine), but the most common symptoms and signs are chronic fever; weight loss; night sweats; and cough, sometimes with hemoptysis. Chest radiograph typically shows upper lobe infiltrates, with or without cavitation, and can be misdiagnosed as a neoplastic process. HIV-positive or immunocompromised patients usually have mediastinal adenopathy, pleural effusions, and a miliary pattern.
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Aortic Valvular Disease. Controversies
CONTROVERSIES
27. Should the Ross procedure ever be performed?
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For: The Ross procedure provides excellent, long-term (sometimes lifelong) hemodynamic relief of aortic stenosis and avoids the need for mechanical valves, thus avoiding the need for anticoagulation. An additional benefit is the regenerative capacity of the aortic autograft; it may actually increase in size as the patient grows.
Against: The Ross procedure is a technically demanding operation and has a significant learning curve with high associated morbidity. The procedure destroys a normal pulmonary valve, thus potentially giving the patient two (instead of one) valve diseases.
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Aortic Valvular Disease
77 AORTIC VALVULAR DISEASE
Christopher D. Raeburn M.D., Alden H. Harken M.D.
1. What are the most common causes of aortic stenosis?
g> Show answer
Rheumatic heart disease is now a rare cause of aortic stenosis, so the most common causes are now congenital anomalies and calcific (degenerative) disease.
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Mitral Regurgitation. Bonus Question
BONUS QUESTION
16. What is systolic anterior motion (SAM) of the mitral valve?
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SAM is a complication of mitral valve repair. After mitral valve repair, the anterior leaflet of the mitral valve may billow into the left ventricular outflow tract during systole, creating two problems: (1) dynamic left ventricular outflow tract obstruction and (2) mitral regurgitation (anterior displacement of the anterior leaflet causes it to be foreshortened). SAM should be suspected if cardiac output is low after mitral valve repair and may be diagnosed by echocardiography. It is exacerbated by an increased contractile state of the myocardium, so inotropic agents should be avoided. Patients with SAM are treated by volume-loading and beta-blocking agents. If these measures fail, the valve should be replaced.
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MITRAL REGURGITATION
76 MITRAL REGURGITATION
David A. Fullerton M.D., Glenn J.R. Whitman M.D.
1. List the causes of mitral regurgitation.
Show answer
* Rheumatic fever
* Endocarditis
* Ruptured chordae tendineae
* Senile mitral annular calcification
* Papillary muscle dysfunction from ischemia
* Annular dilatation from left ventricular dilation
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Mitral Stenosis. Bonus Question
BONUS QUESTION
19. What is the Lutembacher syndrome?
Show answer
Mitral stenosis associated with an atrial septal defect. This results in a left-to-right shunt and overworks the right ventricle.
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Mitral Stenosis
75 MITRAL STENOSIS
David A. Fullerton M.D., Glenn J.R. Whitman M.D.
1. What causes mitral stenosis?
Show answer
Rheumatic fever.
2. Which gender most commonly gets mitral stenosis?
Show answer
Women by a ratio of 3:2.
3. What are the physical findings of mitral stenosis?
Show answer
On ascultation, an opening snap and a diastolic murmer are heard best at the apex.
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Coronary Artery Disease. Controversies
CONTROVERSIES
15. Is there an advantage to surgical revascularization with all arterial conduits?
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The logical extension of the observation that an internal mammary artery has superior patency to a saphenous vein has sparked an interest in total arterial revascularization. Instead of using saphenous veins as bypass conduits, some surgeons also use the right internal mammary artery, the gastroepiploic artery, and the radial artery as bypass conduits instead of vein. Convincing data suggest a survival benefit as well as freedom from angina when the LIM artery is used as a conduit. The data supporting total arterial revascularization are much less clear.
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Coronary Artery Disease
74 CORONARY ARTERY DISEASE
Joseph C. Cleveland Jr., M.D.
1. What is angina, and what causes it?
Show answer
Angina pectoris reflects myocardial ischemia. Patients often describe the sensation as pressure, choking, or tightness. Angina is typically produced by an imbalance between myocardial oxygen supply and myocardial oxygen demand. The classic presentation is a man (male-to-female ratio = 4:1) out shoveling snow on a cold night after a big meal after having a fight with his wife.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
