Cardiac Surgery Clerkship: A Guide for Senior Medical Students (Contemporary Surgical Clerkships)

This quick-reference guide is the first book written specifically for the many third- and fourth-year medical students rotating on the cardiac surgery service. The book focuses on the diagnosis and management of the most common pathologic entities. Each chapter covers history, physical examination, imaging, and common diagnoses. For each diagnosis, the book sets out the typical presentation, options for non-operative and operative management, and expected outcomes. Chapters include key illustrations, quick-reference charts, tables, diagrams, and bulleted lists. Students can read the text from cover to cover to gain a general foundation of knowledge that can be built upon when they begin their rotation, then use specific chapters to review a sub-specialty before starting a new rotation or seeing a patient with a sub-specialty attending. Topics covered include bypass, valve repair and replacement, heart and lung transplantation, congenital heart defects, aortic trauma, and much more. Practical and user-friendly, Cardiac Surgery Clerkship is the ideal, on-the-spot resource for medical students and practitioners seeking fast facts on diagnosis and management. Its bullet-pointed outline format makes it a perfect quick reference, and its content breadth covers the most commonly encountered problems in clinical practice. Editors Addenda Contents Chapter 1: History of Cardiac Surgery Early Heart Surgery (Rehn, Cutler, Gross, Blalock): [1–4] Ludwig Rehn: First Successful Surgery on the Heart Elliott Cutler: The Origin of Heart Valve Surgery Robert Gross: Dawn of Congenital Cardiac Surgery Alfred Blalock: A Landmark Operation in Congenital Heart Surgery The Birth of Open-Heart Surgery: Surface Cooling (Bigelow, Lewis, Swan), Cardiopulmonary Bypass (Gibbon, Kirklin), and Cross-Circulation (Lillehei) [1–3, 5] Wilfred Bigelow: Development of Surface Cooling for Open-Heart Surgery F. John Lewis: First Successful Open-Heart Surgery Henry Swan: Open-Heart Surgery in a Series of Patients John Gibbon: The Heart-Lung Machine for Cardiopulmonary Bypass John Kirklin: Advancement of the Heart-Lung Machine Clarence Walton Lillehei: Cross-Circulation Myocardial Protection (Melrose, Gay and Ebert, Bretschneider, Buckberg, Daggett, del Nido) [1–3, 6] Dennis Melrose: Advent of Cardioplegia William Gay and Paul Ebert: Reemergence of Cardioplegic Solutions Hans-Jürgen Bretschneider: Histidine-Tryptophan-Ketoglutarate (HTK) Cardioplegia Gerald Buckberg: Blood Cardioplegia Willard Daggett: Optimization of Cardioplegia Pedro del Nido: Cardioplegia for Congenital Heart Surgery Valve Repair and Replacement (Starr, Ross, Barratt-Boyes, McGoon, Carpentier, Bentall, Yacoub and David): [1–3, 7] Albert Starr: First Mechanical Heart Valve Donald Ross: Pioneer of Homograft Valve Replacement Brian Barratt-Boyes: Development of Homograft Valves Dwight McGoon: Proficiency in Valve Surgery Alain Carpentier: Xenograft Heart Valves Hugh Bentall: Aortic Root Replacement Sir Magdi Yacoub and Tirone David: Valve-Sparing Aortic Root Replacement Transplantation (Carrel, Shumway, Barnard, DeBakey and Cooley, Cooper): [1–3, 8] Alexis Carrel: Experimental Heart Transplantation Norman Shumway: The Father of Heart Transplantation Christiaan Barnard: First Human-to-Human Heart Transplant Michael DeBakey and Denton Cooley: Ventricular Assist Device and the Artificial Heart Joel Cooper: First Successful Lung Transplant Minimally Invasive Heart Surgery (Chitwood, Cribier): [9, 10] W. Randolph Chitwood: Video-Assisted and Robotic Mitral Valve Surgery Alain Cribier: Percutaneous Valve Surgery References Chapter 2: Surgical Anatomy of the Heart Introduction Surface Anatomy Coronary Vasculature Left Coronary Artery Right Coronary Artery Coronary Veins The Fibrous Skeleton Tricuspid Valve Mitral Valve Pulmonic Valve Aortic Valve Aorta Conduction System References Chapter 3: Preoperative Evaluation and Risk Assessment Introduction Basic Preoperative Patient Evaluation History Physical Exam Laboratory and Imaging Studies Labs Infectious Disease/Microbiology Chest X-Ray (CXR) Electrocardiogram (ECG) Chest CT Computed Tomography Angiography (CTA) of the Coronary Arteries Echocardiography Stress Testing Cardiac Catheterization with Coronary Angiography Viability Studies Cardiopulmonary Exercise Testing (CPET) Pulmonary Function Tests (PFTs) Carotid Artery Studies Risk Models and Categories The Society of Thoracic Surgeons (STS) Risk Models and Short-Term Risk Calculator [20] Additional Preoperative Considerations Consultations MGH Perioperative Medication Management References Chapter 4: Echocardiography Transthoracic Echocardiography (TTE) Transesophageal Echocardiography (TEE) Echocardiography for Common Cardiac Pathologies Valvular Aortic Stenosis (AS) Aortic Regurgitation (AR) Mitral Stenosis (MS) Mitral Regurgitation (MR) Tricuspid Regurgitation (TR) Left Ventricular Function Tamponade and Constriction Diastolic Function Adjuncts for Echocardiography Stress Echocardiography Contrast Echocardiography References Chapter 5: Cardiac CT and MRI Introduction Cardiac CT Indications Patient Selection CT Protocol Imaging Findings Non-contrast/Calcium Score Scan Contrast-Enhanced Scan Coronary Arteries Anomalies Coronary Artery Disease (CAD) Coronary Artery Dissections Coronary Artery Aneurysms Valvular Disease Pre-transcatheter Procedure Assessment Infective Endocarditis Valvular Mass Cardiac Mass Cardiac MR Indications Flow and Function Evaluation Tissue Characterization Patient Selection Protocol Imaging Findings Aorta Indications Imaging Findings Aneurysm Acute Aortic Syndrome Coarctation Pre-procedural CT Double Rule Out Volume Rendered Reconstruction Conclusion References Chapter 6: Coronary Angiography Indications Access Standard Projections and Catheterization Laboratory Setup Physiologic Assessment Additional Imaging Modalities Basics of Percutaneous Coronary Intervention Deciding Between Percutaneous Coronary Intervention Versus Surgical Revascularization PCI Versus Percutaneous Transluminal Coronary Angioplasty (PTCA) Stent Choice and DAPT Duration Right Heart Catheterization Indication Access Data References Chapter 7: Cardiac Anesthesia Hemodynamic and Physiologic Monitoring Required Standard American Society of Anesthesiologists (ASA) Monitoring Advanced Hemodynamic Monitoring Pharmacology of Induction and Maintenance of General Anesthesia Lesion Specific Anesthetic Considerations Use of Vasoactive Medications Pulmonary Artery Catheter Cardiopulmonary Bypass References Chapter 8: Transfusion Medicine and Blood Management During Cardiac Surgery Introduction Preoperative Risk Assessment Preoperative Treatment of Anemia Pharmacologic Interventions Nonpharmacologic Interventions Preoperative Anticoagulant and Antiplatelet Management Anticoagulant Management Antiplatelet Management Intraoperative Blood Management Pharmacologic Interventions for Bleeding Prevention Nonpharmacologic Interventions for Blood Conservation Intraoperative Hemostasis Testing Perfusion Interventions to Reduce Blood Loss Post-bypass and Postoperative Blood Management Laboratory Studies Transfusion Triggers* References Chapter 9: Cardiopulmonary Bypass Basic Components of the Heart-Lung Machine Heart-Lung Machine Safety Cannulation Strategies Standard Heparin Dosage and Reversal Optimal Flow Rates and MAP Cooling and Warming Steps to Initiate and Separate from CPB Initiation Separation Criteria for Discontinuing CPB Circulatory Arrest and Special Considerations Alpha Stat and pH Stat ACP and RCP References Chapter 10: Myocardial Protection Cardiac Metabolic Demand in Different States Basic Elements of Cardioplegia Solution Rapid Cardiac Arrest Buffering of Cardioplegia Solution Avoidance of Substrate Depletion Avoidance of Myocardial Edema Hypothermia Modes of Cardioplegia Delivery Flow and Pressure Achieving Diastolic Arrest Alternate Formulations References Chapter 11: Management of Coronary Artery Disease Brief Epidemiology and Pathophysiology Staples of Medical Management for Stable CAD Indications for Revascularization Conduit Options Basic Steps of Coronary Artery Bypass Grafting (CABG) Using Cardiopulmonary Bypass (CPB) [9] On Pump Versus Off Pump Coronary Artery Bypass References Chapter 12: Mechanical Complications of Myocardial Infarction Introduction Evaluation Presentation Diagnostic Studies Initial Management Acute Mitral Regurgitation Pathogenesis Diagnosis Management Post-infarction Ventricular Septal Defect Pathogenesis Diagnosis Management Surgical VSD Repair Free Wall Rupture Pathogenesis Diagnosis Management Left Ventricular Pseudoaneurysm and Aneurysm LV Pseudoaneurysm LV Aneurysm References Chapter 13: Aortic Valve Repair and Replacement Overview Basic Introduction to Valve Pathologies Aortic Stenosis Aortic Regurgitation Indications for Repair vs Replacement Repair Techniques Replacement Techniques Stented Bioprosthetic Valves Mechanical Valves Stentless Valves Ross Procedure Ozaki Procedure Prosthesis Selection Special Circumstances Small Aortic Root Paravalvular Regurgitation References Chapter 14: Mitral Valve Repair and Replacement Overview [1, 2] Anatomy [3–7] Valve Pathophysiology [3–7, 9, 10] Mitral Regurgitation Mitral Stenosis (MS) Management of Mitral Regurgitation [2–7, 9, 10, 13–27, 28] Decision to Operate Operative Management of Primary (Degenerative) MR Systolic Anterior Motion (SAM) Operative Management of Ischemic (Secondary) MR Management of Mitral Stenosis [2–7, 9, 10, 29–32] Decision to Operate Operative Technique Open Commissurotomy Mitral Valve Replacement (MVR) Mechanical Versus Bioprosthetic MVR Special Operative Considerations [4–7, 16] Mitral Annular Calcification References Chapter 15: Tricuspid Valve Repair and Replacement Introduction Anatomy Pathology Primary Tricuspid Regurgitation Congenital Acquired Secondary (Functional) Tricuspid Regurgitation Tricuspid Stenosis Tricuspid Atresia History and Physical Exam Physical Exam Findings Imaging Echocardiography Cross-Sectional Imaging Cardiac Catheterization Indications for Intervention Tricuspid Regurgitation Tricuspid Stenosis Congenital Heart Disease Prosthetic Tricuspid Valves Tricuspid Valve Surgery Operative Approach Tricuspid Valve Repair (Fig. 15.1) Tricuspid Valve Replacement Prosthesis Selection Postoperative Considerations References Chapter 16: Pulmonary Valve Repair and Replacement Introduction Anatomy Pathology Pulmonary Regurgitation and Stenosis Congenital Acquired History and Physical Exam Physical Exam Findings Imaging Echocardiography Cross-Sectional Imaging Cardiac Catheterization Indications for Intervention Pulmonary Regurgitation Pulmonary Stenosis Congenital Heart Disease Prosthetic Pulmonary Valves Pulmonary Valve Surgery Operative Approach Pulmonary Valve Replacement Right Ventricular Outflow Tract Interventions for Pulmonary Stenosis Congenital Heart Disease Prosthesis Selection Postoperative Considerations Right Ventricle to Pulmonary Artery Conduits Commonly Used Types of RV-PA Conduits (Fig. 16.3) Special Circumstances References Chapter 17: Transcatheter Therapies for Structural Heart Disease Overview Structural Heart Pathologies Treated with Transcatheter Therapies Aortic Valve Disease Aortic Valve Bioprosthetic Failure Mitral Valve Disease Tricuspid Valve Disease Pulmonary Valve Disease Atrial Septal Defect, Ventricular Septal Defect, and Paravalvular Leaks Treatment Options and Considerations in TAVR Patient Selection: SAVR vs. TAVR Prosthesis Access Imaging Evaluation in TAVR Access Valve Morphology and Sizing Basic Steps of Transfemoral TAVR Access and Preparation Valve-Crossing and Deployment Closure Complications in TAVR Conclusions References Chapter 18: Management of Endocarditis Overview Common Organisms and Etiology Clinical Presentation Diagnostic Criteria Antimicrobial Management Surgical Intervention Timing and Indications for Operation on Left-Sided Valves Timing and Indications for Operation on Right-Sided Valves Complex Multi-Valve Endocarditis Timing of Operative Intervention After Acute Stroke Special Considerations Prosthesis Selection Prosthetic Valve Endocarditis Intravenous Drug Use References Chapter 19: Aneurysmal Disease of the Ascending Aorta, Root, and Arch Anatomy Etiology of Dilation Aortic Root Surgery Aortic Arch Surgery Surgical Principles and Management References Chapter 20: Descending Thoracic and Thoracoabdominal Aortic Aneurysms Anatomy, Definition, and Etiology History and Physical Tests Imaging Evaluation Labs Management and Treatment Operative Repair: Open vs. Endovascular Endovascular Repair of DTAA (TEVAR) Preoperative planning Operative Repair Open Repair Preoperative Planning Physiologic Evaluation Operative Steps Anesthesia and Positioning Incision and Exposure Extracorporeal Circulation Arterial Reconstruction Closure Postoperative Care and Complications Spinal Cord Ischemia Bleeding Pulmonary Ongoing Surveillance Further Reading Chapter 21: Acute Aortic Syndromes Definition and Outcomes Anatomy and Classification Pathophysiology and Clinical Presentation Diagnosis CT Scan Transesophageal Echocardiogram (TEE) MRI Indications for Surgery Ascending Aorta Descending Aorta Cannulation Strategy Femoral Axillary, Right Subclavian, Innominate, and Other Arch Branch Arterial Cannulation Direct Aortic Malperfusion Syndrome Malperfusion vs. Malperfusion Syndrome Endovascular Fenestration and Stenting Endovascular Therapy References Chapter 22: Aortic Trauma Mechanisms of Aortic Trauma Mechanisms of Thoracic Aortic Trauma Mechanisms of Abdominal Aortic Trauma Initial Evaluation of Thoracic Aortic Trauma Initial Evaluation of Abdominal Aortic Trauma Indications for Intervention Operative Approach References Chapter 23: Acute and Chronic Pulmonary Embolism Introduction Acute Pulmonary Embolism Presentation and Diagnosis Risk Stratification Treatment of Acute Pulmonary Embolism Indications for Surgery Operative Technique for Pulmonary Embolectomy Chronic Thromboembolic Disease Pathogenesis Presentation and Diagnosis Indications for Surgery Operative Technique for Pulmonary Thromboendarterectomy References Chapter 24: Surgery for Atrial Fibrillation Surgery for Atrial Fibrillation Intro Atrial Fibrillation Classification Surgical Treatment Options Cox-MAZE Pulmonary Vein Isolation (PVI) Management of the Left Atrial Appendage (LAA) References Chapter 25: Pericardial Disease Anatomy Etiology Physiology History Physical Exam Imaging Indication for Surgery Operative Technique References Chapter 26: Cardiac Neoplasms Incidence Workup Differential Diagnosis Myxoma Papillary Fibroelastoma Sarcoma Surgical Resection of Primary Malignancies Role of Cardiac Surgery in the Management of Metastatic Disease References Chapter 27: Hypertrophic Cardiomyopathy Clinical Presentation Diagnostic Evaluation of HCM Management of HCM Transaortic Septal Myectomy Transatrial Myectomy Benefits and Risks of Septal Myectomy Alcohol Septal Ablation References Chapter 28: Temporary Mechanical Circulatory Support Intra-Aortic Balloon Pump Indications Placement/Positioning Settings and Augmentation Assessment Weaning Removal Impella® Indications Placement/Positioning Settings Weaning Removal Protek Duo/LifeSparc® System Indications Placement/Positioning Settings Weaning Removal Temporary Implantable Biventricular Assist Devices Indications Placement/Positioning Settings Weaning Removal Other Devices TandemHeart® Impella® RP Extracorporeal Pumps References Chapter 29: Extra-Corporeal Membrane Oxygenation ECMO Configurations [1] Indications V-V ECMO [1–3] V-A ECMO [1, 4] V-P ECMO Contraindications [3, 6] Cannulation Strategies Nomenclature V-V ECMO [1, 3, 7] V-A ECMO [1, 4] Circuit Function and Monitoring While on ECMO [8] Weaning ECMO [1] Complications and Troubleshooting [4, 9] North-South Syndrome Left Ventricular Distension [1] Thrombosis Limb Ischemia References Chapter 30: Durable Mechanical Circulatory Support Left Ventricular Support Indications [1–7] Devices [3, 5, 8–10] REMATCH Clinical Trial [1] Surgical Implantation Technique [11–13] Post-operative Complications [4, 5, 8, 10, 11] Right Ventricular Support [3, 11, 14, 15] References Chapter 31: Heart Transplantation Introduction Pre-transplantation Assessment Stages of Heart Failure Indications for Heart Transplantation Contraindications for Heart Transplantation Criteria for Medical Urgency Donor Selection [5] DBD DCD [6] Surgical Techniques [8] Preservation Options Donor Cardiectomy: General Sequence During DBD Procurement Donor Cardiectomy in DCD NRP Protocol DPP Protocol Implant Technique Immunosuppression Post-operative Care Considerations Outcomes References Chapter 32: Lung Transplantation Indications for Transplant and Recipient Selection [1, 2] Lung Allocation Score [3] Single vs. Double Lung Transplant [4–6] Donor Selection [7, 8] Donor Pneumonectomy [9, 10] Recipient Procedure [11] Immunosuppression [12, 13] Outcomes [13–15] References Chapter 33: Adult Congenital Heart Disease Adult Presentation of Common Congenital Heart Defects Tetralogy of Fallot Anatomy/Pathophysiology Initial Operation Common Complications Reoperative Surgery Coronary Artery Anomalies Anomalies of Origin Imaging Risk of Sudden Cardiac Death [4] Surgical Repair Vascular Rings Anatomy/Pathophysiology [9] Normal Anatomy/Development (Fig. 33.5) Vascular Ring Anatomy Presentation Kommerell’s Diverticulum Adult Coarctation of the Aorta (CoA) Presentation Surgical Repair [11] Bicuspid Aortic Valve Anatomy Presentation Surgery Cor Triatriatum Dexter [12] Anatomy Presentation Surgical Repair Complex Adult Congenital Heart Defects Single Ventricle [14] Single Ventricle Physiology Adults with Single Ventricle CHD Fontan Repair Transplant and Mechanical Circulatory Support References Chapter 34: Teamwork in the Cardiac Surgical Operating Room Roles/Responsibilities of Cardiac OR Teams Cardiac Surgery Anesthesia Perfusion Nursing Scrub Person Variations in Cognitive Load During Cardiac Surgery Impact of Preoperative Briefing (“Huddle”) Promoting a Culture of Safety in the OR References Chapter 35: Principles of Postoperative Care Assessment and Goals for the Immediate Postoperative Period [1–4] Hemodynamic Evaluation [2, 3, 5–16] Laboratory Evaluation [2, 17, 18] Chest X-ray Evaluation [2, 19] Warming, Weaning Sedation, Waking [2, 3] Fluid Management [2, 3, 10, 20] Use of Sodium Bicarbonate [21–23] Goals and Criteria for Extubation [2, 24, 25] Complications After Cardiac Surgery Postoperative Bleeding [6, 26–28] Tamponade [2, 3, 6, 29–31] Atrial Fibrillation [2, 5, 6, 32–34] Stroke [6, 35, 36] References Index