Cardiac, Thoracic, Esophagus Absite Flashcards

Front 1

Pt presents c/ dysphagia and barium swallow shows "bird beak" narrowing
-This suggests _

Back 1

Achalasia:
-Neuronal degeneration in muscle wall (decreased ganglion cells in Auerbach's plexus) ->
Failure of peristalsis, poor LES relaxation after a food bolus ->
Dysphagia, regurgitation, weight loss, resp sx
-Can get tortuous, dilated esophagus, epiphrenic diverticula, BIRDBEAK appearance
-Manometry: HIGH LES PRESSURE, incomplete LES relaxation, NO PERISTALSIS

-Tx: Ca channel blocker, LES dilation 60% effective
-Nitrates
-Failure of medical mgmt => Heller myotomy = L thoracotomy, transect cicular layer of upper and lower esophagus. Also do partial Nissen fundoplication
-Trypanosoma cruzi => similar sx

Front 2

Pt presents c/ dysphagia and barium swallow shows "bird beak" narrowing
-This suggests _
-Must R/o _

Back 2

Achalasia:
-Neuronal degeneration in muscle wall (decreased ganglion cells in Auerbach's plexus) ->
Failure of peristalsis, poor LES relaxation after a food bolus ->
Dysphagia, regurgitation, weight loss, resp sx
-EGD to R/O PSEUDOACHALASIA = TUMOR @ GE JUNCTION
-Confirm c/ MANOMETRY: HIGH LES PRESSURE, incomplete LES relaxation, NO PERISTALSIS

-Tx: Ca channel blocker, LES dilation 60% effective
-Nitrates
-Failure of medical mgmt => Heller myotomy = L thoracotomy, transect cicular layer of upper and lower esophagus. Also do partial Nissen fundoplication
-Trypanosoma cruzi => similar sx

Front 3

Lady presents to clinic c/ dysphagia, regurgitation, weight loss, resp sx
-Barium swallow shows _
-Manometry shows increased LES pressure, incomplete LES relaxation, no peristalsis
-This is consistent c/ diagnosis of _

(manometry normal on L, abnl on R)

Back 3

Achalasia:
-Neuronal degeneration in muscle wall ->
Failure of peristalsis, poor LES relaxation after a food bolus ->
Dysphagia, regurgitation, weight loss, resp sx
-Can get tortuous, dilated esophagus, epiphrenic diverticula, BIRDBEAK appearance
-Manometry: increased LES pressure, incomplete LES relaxation, NO perstalsis

-Tx: Ca channel blocker, LES dilation 60% effective
-Nitrates
-Failure of medical mgmt => Heller myotomy = L thoracotomy, transect cicular layer of upper and lower esophagus. Also do partial Nissen fundoplication
-Trypanosoma cruzi => similar sx

Front 4

during attempted achalasia dilation, gastroenterologist not successful but pt develops chest pain p/ procedure.
-Gastrograffin study normal but thin barium swallow shows peforation
-Operative repair of injury should include

Back 4

Operative repair: L thoracotomy, myotomy to see extent of injury, butressed repair c/ intercostal muscle or pleura, then short segment myotomy on side opposite of repair to relieve the obstruction

Front 5

manometry shows failure of LES to relax, lack of peristalsis. Diagnosis is _

Back 5

The manometric criteria of Achalasia are failure of the LES to relax reflexively with swallowing and lack of progressive peristalsis throughout the length of the esophagus. The distal esophageal HPZ pressure is generally normal or elevated, but marked hypertonicity of DES is not seen.

Front 6

A 40 year-old male presents with symptoms and radiograph consistent with Achalasia. An esophagoscopy fails to reveal neoplasia. The next test to confirm diagnosis is

Back 6

The most important study to diagnose Achalasia is manometry. This study will confirm the failure of LES to relax reflexively with swallowing and lack of progressive peristalsis throughout the length of esophagus.

Front 7

#1 esophageal cancer = _

Back 7

Adenocarcinoma = #1 esophageal cancer

Front 8

#1 lung cancer = _

Back 8

Adenocarcinoma = #1 lung cancer

Front 9

type _ alveoli => functional gas exchange

Back 9

Type 1 alveoli: functional gas exchange
Type 2 alveoli: product surfactant, 1 % of alveoli

Front 10

type _ alveoli => produce surfactant

Back 10

Type 1 alveoli: functional gas exchange
Type 2 alveoli: product surfactant, 1 % of alveoli

Front 11

Angioplasty => __ restenosis by 1 yr
-Vein graft => __% 5-year patency
-IMA graft => __% 20-yr patency

Back 11

Angioplasty:
-20% restenosis by 1 year
-vein graft has 80% 5-yr patency
-IMA graft has 95% patency @ 20 yrs

Front 12

#1 cause of ascending aortic aneurysms = _

Back 12

#1 cause of ascending aortic aneurysms =
CYSTIC MEDIAL NECROSIS
(e.g. idiopathic #1, Marfans)

Front 13

#1 cause of descending aortic aneurysms = _

Back 13

#1 cause of descending aortic aneurysms =
ATHEROSCLEROSIS

- can become large before symptomatic
- 5-10% risk of paraplegia
- repair indications same as ascending AA
- reimplant intercostal vessels below T8 to reduce risk of paraplegia

Front 14

Pt is s/p aortic arch aneurysm repair near the L subclavian artery and deveops a pleural effusion.
Must r/o _
-Tx is _

Back 14

Chylothorax s/p distal aortic arch procedure
-Around the thoracic duct, where it has crossed over to the L side
-Can cause LEFT chylothorax
-Milky white fluid c/ increases lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-Thoracic duct runs on R chest until T5-> to L side
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful

Front 15

The _ runs along the R side + dumps into the SVC

Back 15

AZYGOS vein runs posterior R thorax, arches over R main bronchus, + dumps into the SVC
-Transports deoxygenated blood from posterior walls of the thorax + abdomen +/- thoracic , bronchial, even gonadal veins.
- formed by union of the ascending lumbar veins + R subcostal veins @ T12 level

Front 16

Pt has longstanding GERD, high grade dysplasia on EGD.
-Therapy is _

Back 16

Barrett's espophagus:
-longstanding reflux -> sq metaplasia to columnar epithelium
-50x risk of esophageal adenoca (1-2% risk total)
-10-20% of pts c/ high grade dysplasia have undiagnosed esophegeal cancer already
-Ass'd c/ p53 (tumor supressor gene)
-Severe dysplasia => esophagectomy
-Uncomplicated Barrett's is treated like GERD => PPI, Nissen
-Nissen decreases esophagitis, progression of metaplasia (does NOT reverse metaplasia or prevent malignancy). Still need f/u EGD for lifetime

Front 17

Barrett's esophagus:
-what type of cell change?
-_-_% risk of esophageal adenoca
(_-_x risk of ca)
-Ass'd c/ _ tumor supressor gene

Back 17

Barrett's espophagus:
-longstanding reflux -> sq metaplasia to columnar epithelium
-50x risk of esophageal adenoca (1-2% risk total)
-10-20% of pts c/ high grade dysplasia have undiagnosed esophegeal cancer already
-Ass'd c/ p53 (tumor supressor gene)
-Severe dysplasia => esophagectomy
-Uncomplicated Barrett's is treated like GERD => PPI, Nissen
-Nissen decreases esophagitis, progression of metaplasia (does NOT reverse metaplasia or prevent malignancy). Still need f/u EGD for lifetime

Front 18

Boerhaave's:
-How do you decide which side to do the thoracotomy on?

Back 18

Boerhaave's:
-Proximal 2/3 of thoracic esophagus => R thoracotomy
-Distal 1/3 of thoracic esophagus (more likely) => L thoracotomy

Front 19

Alcoholic man is taken to the OR hypotensive, tachycardic , L effusion, and pneumothorax.
Suspect _
Most sensitive test is _

Back 19

Boerhave's syndrome:
-Forceful vomiting -> esophageal perforation, usually in L posterolateral wall @ level T8 (inferior esophagus), 3-5 cm above GE junction -> chest pain
-Hartman's sign = mediastinal crunching on ascultation
-Early diagnosis, tx improve survival
-Dx: gastrograffin swallow, followed by thin barium swallow (CT chest +PO/IV contrast is less sensitive)
-Lower 1/3 => L thoracotomy, longitudinal myotomy to visualize full extent of injury, primary repair + chest tube
-Upper 2/3 of esophagus => R thoracotomy
-Esophagectomy for delated presentation, gross mediastinitis

Front 20

Most common location for esophageal perforation in Boerhave's syndrome is _
-Therefore the most common operative approachs is by _

Back 20

Boerhave's syndrome:
-Forceful vomiting -> esophageal perforation, usually in L posterolateral wall @ level T8 (inferior esophagus), 3-5 cm above GE junction -> chest pain
-Hartman's sign = mediastinal crunching on ascultation
-Early diagnosis, tx improve survival (85% mortality if >36 hrs until dx)
-Dx: gastrograffin swallow, followed by thin barium swallow (CT chest +PO/IV contrast is less sensitive)
-Lower 1/3 => L thoracotomy, longitudinal myotomy to visualize full extent of injury, primary repair + chest tube
-Upper 2/3 of esophagus => R thoracotomy
-Esophagectomy for delated presentation, gross mediastinitis

Front 21

Pt is POD 6 after R pneumonectomy for lung cancer and develops fever, serosanguinous sputum
-CXR: lower air-fluid level on pneumonectomy side, but new ipsilateral infiltrate

Back 21

Broncho-pleural fistula:
-Serosanguinous sputum, change in air-fluid level on CXR, new infiltrate
-Infiltrate is 2/2 aspiration of residual fluid in post-pneumonectomy air space into remaining lung
-More common after pneumonectomy vs. lobectomy
-Diagnose via bronchoscopy
-Tx: thoracotomy, washout -> close stump -> muscle flap over bronchus -> drain + abx

Front 22

Is bronchopleural fistula more common after lobectomy or pneumonectomy?

Back 22

Broncho-pleural fistula:
-Serosanguinous sputum, change in air-fluid level on CXR, new infiltrate
-Infiltrate is 2/2 aspiration of residual fluid in post-pneumonectomy air space into remaining lung
-More common after pneumonectomy vs. lobectomy
-Diagnose via bronchoscopy
-Tx: thoracotomy, washout -> close stump -> muscle flap over bronchus -> drain + abx

Front 23

What is a Blalock-Taussif (BT) shunt?

Back 23

Tetrology of Fallot:
-#1 congenital cyanotic heart defect
-Anterior + superior displacement of infundibular septum ->
1. malalignment VSD
2.) overriding aortic valve
3. Valvular + infundibular pulmonic stenosis
4.) LV outflow obstruction -> hypertrophic R ventricle

-Tx: beta blocker
-Operate if increased cyanosis
-BLALOCK-TAUSSIG (BT) shunt can be used for palliation to delay repair

Front 24

The internal mammary arteries branch off the _ arteries, collateralize with the _ arteries

Back 24

Internal mammary artery:
-off subclavians
-best conduit for CABG: >90% 10-yr graft patency rate
-collateralizes with SUPERIOR EPIGASTRIC artery

Front 25

pt is 7 days s/p MI and suddenly develops new murmur, hypotension requiring volume and pressors
-Suspect 2 major causes
-Next step = _

Back 25

New murmur or hypotension 7 days after MI;
-Possible ACUTE MITRAL VALVE INSUFF or POST-MI VSD
-Get echo

Front 26

Biggest RF for mortality following CABG is _

Back 26

Biggest RF for mortality following CABG = POST-OP CARDIOGENIC SHOCK
-Treat pt c/ shock after MI with PTCA, IABP, medical therapy, NOT CABG

Front 27

IMA graft to LAD has predicted patency of _% at 20 years

Back 27

IMA graft to LAD has predicted patency of 90% at 20 years

Front 28

SVG graft to a non-LAD coronary artery has predicted patency of _% at 20 years

Back 28

SVG graft has predicted patency of 80% at 20 years

Front 29

CABG indications (4)

Back 29

CABG indications:
-intractable symptoms
3-vessel dz, 70% LAD + 1 other vessel, or 50% left main

Front 30

Most important determinent of O2 consumption is _

Back 30

Most important determinent of O2 consumption = WALL TENSION

Front 31

a left-sided chylothorax is most commonly caused by what type of surgery?

Back 31

Distal aortic arch procedure (e.g. aneurysm repair near L SCA) = #1 cause of L Chylothorax
-Milky white fluid, high lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-50% 2/2 trauma or iatrogenic injury, 50% 2/2 posterior mediasinal tumor (esp. lymphoma; 2/2 tumor burden in lymphatics)
-Thoracic duct runs on R chest until T5-> to L side
-Injury above T5-6 => L chylothorax
-Injury below T5-6 => R chylothorax
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful
-Malignant etiology + failure of conservative tx -> mechanical or talc pleurodesis (less successful)

Front 32

Chylothorax:
-Typical management is _

Back 32

Chylothorax;
-Milky white fluid, high lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-50% 2/2 trauma or iatrogenic injury
-50% 2/2 posterior mediasinal tumor (esp. lymphoma; 2/2 tumor burden in lymphatics)
-Thoracic duct runs on R chest until T5-> to L side
-Injury above T5-6 => L chylothorax
-Injury below T5-6 => R chylothorax
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful
-Malignant etiology + failure of conservative tx -> mechanical or talc pleurodesis (less successful)

Front 33

Pt gets chylothorax after Ivor-Lewis esophagectomy.
Should be on the _ side
Tx: _

Back 33

Chylothorax s/p Ivor-Lewis
= abdominal incision + R thoracotomy
-Can cause RIGHT chylothorax
-Milky white fluid c/ increases lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-Thoracic duct runs on R chest until T5-> to L side
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful

Front 34

Distal aortic arch procedures can present with a _-sided chylothorax

Back 34

Chylothorax;
-Milky white fluid c/ increases lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-50% 2/2 trauma or iatrogenic injury
-50% 2/2 tumor (lymphoma most common, due to tumor burden in lymphatics)
-Thoracic duct runs on R chest (i.e. damage during Ivor-Lewis) until T5-> to L side (i.e. damage during distal aortic arch procedures)
-Injury above T5-6 => L chylothorax
-Injury below T5-6 => R chylothorax
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful
-Malignant etiology + failure of conservative tx -> mechanical or talc pleurodesis (less successful)

Front 35

4 accessory muscles for inspiration

Back 35

Accessory muscles:
SCM
Levators
Serratus posterior
Scalenes

Front 36

what are the 3 holes in the diaphragm and their T-levels?

Back 36

Diaphragm holes:
T8: IVC
T10: esophagus, vagi
T12: thoracic duct, aorta

Front 37

Lady presents to clinic c/ dysphagia, regurgitation, weight loss, resp sx
-Manometry shows increased amplitude and duration of esphageal contractions, disorganized contractions, normal LES tone
-This is consistnet c/ diagnosis of _

Back 37

Diffuse esophageal spasm:
-Presentation: chest pain plus the other sx which are similar to achalasia
-+/- psych history
-Manometry: frequent dysorganized body contractions of high amplitude and duration, NORMAL LES TONE
-Nutcracker esophagus presents c/ similar sx but high amplitude peristalsis
-Tx: MEDICAL = CA CHANNEL BLOCKER, nitrates, antispasmodics, Heller myotomy = transect circular layer of upper and lower esophagus
-Surgery better at resolving dysphagia than pain
-Treatment less effective for DES than for achalasia

Front 38

Diffuse esophageal spasm:
-Tx is _

Back 38

Diffuse esophageal spasm:
-Presentation: chest pain plus the other sx which are similar to achalasia
-+/- psych history
-Manometry: frequent dysorganized body contractions of high amplitude and duration, NORMAL LES TONE
-Nutcracker esophagus presents c/ similar sx but high amplitude contractions
-Tx: MEDICAL = CA CHANNEL BLOCKER, nitrates, antispasmodics, Heller myotomy = transect circular layer of upper and lower esophagus
-Surgery better at resolving dysphagia than pain
-Treatment less effective for DES than for achalasia

Front 39

Ductus arteriosus shunts blood from fetal _ -> _

Back 39

Ductus arteriosus:
-L pulmonary artery -> descending aorta
-Shunts blood from fetal lungs

Front 40

Ductus venosum shunts blood from fetal _ -> _

Back 40

Ductus venosum:
-Portal vein -> IVC
-Shunts blood from fetal liver

Front 41

Pt presents c/ dysphagia. -
Best initial test = _

Back 41

Dysphagia or Odynophagia:
-Barium swallow = best initial test
(EGD, CT not as sensitive)

Front 42

Lady presents to clinic c/ difficulty swallowing solids.
-1st step _

Back 42

Barium swallow = 1st test for dysphagia or odynophagia
(EGD, CT less sensitive in picking up abnormalities)

Front 43

What is Eisenmenger's syndrome:

Back 43

R -> L shunts cause cyanosis
-tetrology, transposition, truncus arteriosus
-Cyanosis -> polycythemia, strokes, brain abscess, endocarditis, hypertrophic osteoarthropathy
-Children squat to increae SVRI (SVR/BSA), decrease shunt
-Eisenmengers: pt has L->R shunt -> pulm HTN -> to R->L shunt (generally irreversible)

Front 44

patient s/p Ivor-Lewis esophagectomy POD#6 develops fevers, increased WBC count.
After IV fluids and sending cx, next step = _

Back 44

Suspected esophageal leak s/p esophagectomy => gastrograffin then thin barium swallow to diagnose leak
-Reexplore if non-contained leak indentified
-If tiny leak, can repair + cover with intercostal muscle
-If large leak, take down anastomosis, resect necrotic portion, place drains, perform esophagostomy, then possibly reconnect in 3 mo c/ colonic interposition

Front 45

Esophagus layers:
-no serosa
-_= strongest layer
(in small bowel, _ = strongest)

Back 45

Esophagus layers:
-no serosa
-mucosa = strongest layer
(in small bowel, submucosa = strongest)

Front 46

Upper esophageal sphincter pressure @ rest is ~_ mmHg
During early part of swallow is ~ _mmHg

Back 46

UES = cricopharyngeus
-At rest: ~70 mmHg
Early swallow: ~ 15 mmHg
-Zenker's diverticulum: cricopharyngeous doesn't relax c/ swallowing -> elevated UES pressures -> creates false diverticulum

Front 47

Lower esophageal sphincter pressure @ rest is ~_ mmHg
During swallow is ~ _mmHg

Back 47

LES pressure
-At rest: ~15 mmHg
During swallow: ~ 0 mmHg
-GERD: low LES pressure @ rest

Front 48

what swallowing disease increases the risk of esophageal cancer?

Back 48

Achalasia increases the risk of esophageal cancer

Front 49

Pt presents c/ dysphagia.
-Barium swallow shows mass
-UGI shows smooth intrusion into the lumen
-Differential includes 2 things...

Back 49

1. Leiomyoma
2. GIST (much less common)

Don't biopsy, just enucleate from wall (this is tx for leiomyoma)

Front 50

You believe that a patient has an esophageal leiomyoma.
-Workup includes _
-During workup, do NOT do _
-Therapy is _

Back 50

Esophageal leiomyoma:
-=1 benign esophageal tumor
-Sx: dysphagia, pain, usually in lower 2/3 of esophagus
-Submucosal (confined to muscularis propia, no mucosal component)
-Dx: esophagram, endoscopy to r/o cancer
-Do not biopsy => can form scar, make later resection difficult, increases likelihood of disrupting the mucosa
->5 cm or symptomatic => excision (enucleation) via thoracotomy

Front 51

45 yo male presents with recurrent dysphagia and now with retrosternal vague pressure. Upper endoscopy reveals a lesion in lower third of esophagus with grossly normal overlying mucosa. Biopsy reveals a normal mucosal histology. What is the best treatment for this patient?

Back 51

Enucleation of mass. This patient likely has esophageal leiomyoma, a lesion occurring in 3-10% of population between 20-50 years of age. Submucosal enucleation if symptomatic or >5 cm. Generally biopsy is not recommended, as it may complicate the enucleation by scarring. Results are excellent.

Front 52

Gastroenterologist is attempting balloon dilation for achalasia, but not able to complete it
-Pt c/o chest pain post-op, CXR shows L effusion
-Gastrograffin study normal but thin barium swallow shows perforation proximal to LES into chest
-Management consists of _

Back 52

Esophageal perf into chest 2/2 dilation for achalasia
-must to L THORACOTOMY for free perforation into L chest ->
myotomy to see extent of injury, buttress respair c/ intercostal muscle or pleura, then do short segment myotomy on other size to relieve obstruction
-If contralateral myotomy nor done, obstruction neat LES will remain

Front 53

What is the blood supply to the cervical esophagus?
abdominal esophagus?

What is arterial supply to gastric tube for esophageal reconstruction?

Back 53

Arterial supply to esophagus:
Cervical: inf thyroid A.
Abdominal (inc. GE junction): L gastric A., inferior phrenic A's
Gastric tube for reconstruction: RIGHT GASTROEPIPLOIC

Front 54

esophageal reconstruction:
-__ artery is main supply to stomach when used to replace esophagus

Back 54

esophageal reconstruction:
-R GASTROEPIPLOIC ARTERY = main supply to stomach when used to replace esophagus

Front 55

Patient is POD 6 s/p Ivor-Lewis and develops fever, increased WBC.
-Next step = _

Back 55

Esophagectomy
-5% surgical mortality, 20% cure rate
-Divide L gastric, short gastrics -> R gastroepiploic becomes the blood supply to stomach
-Transhiatal: abdominal + neck incisions, may have lower mortality due to less fewer esophageal leaks c/ cervical anastomosis
-Ivor-Lewis: abdominal incision + R thoracotomy, exposes whole esophagus, intrathoracic anastomosis
-Suspect POST-OP LEAK => gsatrograffin swallow, followed by thin barium swallow

Front 56

Patient is POD 6 s/p Ivor-Lewis and develops fever, increased WBC.
-Gets gastrograffin study, followed by thin barium -> shows non-contained constrast leak @ level of anastomosis
-Next step = _

Back 56

Patient is POD 6 s/p Ivor-Lewis and develops fever, increased WBC.
-Gets gastrograffin study, followed by thin barium -> shows non-contained constrast leak @ level of anastomosis
-RE-EXPLORE to find source of leak
-If it's just a tiny hole at anastomosis with viable tissue surrounding, then repair + reinforce with pleura, pericardial fat, or intercostal muscle, and place drains -> NPO + J-tube feeds x 1 week -> repeat swallow study

Front 57

Patient is POD 6 s/p Ivor-Lewis and develops fever, increased WBC.
-Gets gastrograffin study, followed by thin barium -> shows non-contained constrast leak @ level of anastomosis
-Re-explore, find large area of necrosis in stomach
-Next step = _

Back 57

Patient has leak after esophagectomy, large area of necrotic stomach on re-exploration.
-Take down anastomosis, resect necrotic portion of stomach, perform esophagostomy
-Wait 3 MONTHS before re-anastomosis, likely c/ colonic interposition

Front 58

Esophagectomy:
-_%cure rate
-_% mortality

Back 58

Esophagectomy
-5% surgical mortality, 20% cure rate
-Divide L gastric, short gastrics -> R gastroepiploic becomes the blood supply to stomach
-Transhiatal: abdominal + neck incisions, may have lower mortality due to less fewer esophageal leaks c/ cervical anastomosis
-Ivor-Lewis: abdominal incision + R thoracotomy, exposes whole esophagus, intrathoracic anastomosis
-3-hole: abdominal, thoracic, and cervical incisions
-Requires pyloromyotomy
-Colonic interposition: for young pts c/ benign dz, to preserve gsatric fx, 3 anastomoses required, blood supply depends on marginal vessels
-Contrast study POD 7 to r/o leak
-Post op stricture: most can be dilated
-Palliative esophagectomy indicated in most circumstances

Front 59

what are the indications for neoadjuvant chemo/XRT for GE junction cancer?

Back 59

GE junction cancer: neoadjuvant chemo/CXT needed if T3/4 or N+ (determined by EUS)
-Generally surgery 1st if T1/2
-Do staging c/ PET CT

Front 60

Pt has type _ hiatal hernia:
-Hole in diaphragm beside esophagus
Tx is _

Back 60

Type 2 hiatal hernia:
-Paraesophageal, 2/2 hole in diaphragm beside esophagus, normal GE junction
-Sx: chest pain, dysphagia, early satiety
-Tx: REPAIR 2/2 high risk of incarceration
-Nissen needed to anchor stomach, since diaphragm repair can affect LES

Front 61

Most patients with significant reflux have a type _ hiatal hernia

Back 61

Type 1 hiatal hernia:
-Most pts c/ significant GERD have a type 1 hiatal hernia
-Most pts c/ type 1 hernia do NOT have GERD
-=sliding hernia 2/2 hiatal dilation (most common)

Front 62

What is therapy for a type 2 hiatal hernia?

Back 62

Type 2 hiatal hernia:
-Paraesophageal, 2/2 hole in diaphragm beside esophagus, normal GE junction
-Sx: chest pain, dysphagia, early satiety
-Tx: REPAIR 2/2 high risk of incarceration
-Nissen needed to anchor stomach, since diaphragm repair can affect LES

Front 63

What is a type 4 hiatal hernia?

Back 63

Type 4 hiatal hernia;
-Whole stomach in chest, plus another organ (e.g. colon, spleen)

Front 64

Cachetic pt presents c/ eyelid droop and tiny pupil
-Suspect _
-Mechanism is _
-Tx is _

Back 64

Horner's syndrome 2/2 pancoast tumor = superior sulcus tumor:
-Invasion of sympathetic chain @ T1 -> ptosis, miosis, anhydrosis
-Superior sulcus tumors that invade the sympathetic ganglia only or just the lowest root of the brachial plexus can be resected

Front 65

What is hypertrophic osteoarthropathy?

Back 65

Hypertrophic osteoarthropathy

Front 66

IABP:
-works by 2 mechanisms
-inflates 40 msec before _ wave, deflates with the _ wave

Back 66

IABP:
-augments diastolic coronary blood flow, reduces afterload by inflating during diastole
-inflates 40 msec before T wave; deflates with P wave

Front 67

the internal mammary arteries branch off the _ arteries

Back 67

Internal mammary AKA internal thoracic artery:
-From subclavian artery (inferior surface of the 1st part of SCA, opposite the thyrocervical trunk).
-Descends behind the upper six ribs within 2 cm of the sternal edge.
-Gives origin to the pericardiacophrenic artery, mediastinal arteries, pericardial branches, sternal branches, anterior intercostal branches and perforating branches.
-Divides into the MUSCLOPHRENIC and SUPERIOR EPIGASTRIC ARTERIES at the sixth intercostal space.

Front 68

normal LES pressure @ rest and during swallow are ...

Back 68

LES pressure
-At rest: ~15 mmHg
During swallow: ~ 0 mmHg
-GERD: low LES pressure @ rest

Front 69

In a child with L-> R shunt, what do you look for to detect CHF?

Back 69

L->R shunts:
-VSD, ASD, PDA
-cause CHF
-Failure to thrive, increased HR, tachypnea, hepatomegaly
-HEPATOMEGALY = 1st sign of CHF in child

Front 70

The _ runs along the R side, crosses midline @ T4-5, dumps into L SC vein @ junction c/ IVC

Back 70

THORACIC DUCT runs along the R side, crosses midline @ T4-5, dumps into L SC vein @ junction c/ IVC

Front 71

The _ mainstem bronchus is longer than the _

Back 71

LEFT mainstem bronchus is longer than RIGHT

Front 72

_ pulmonary artery is longer than _ before 1st branch

Back 72

RIGHT pulmonary artery is longer than LEFT before 1st branch

Front 73

R lung volume = _%, L lung volume = _%

Back 73

R lung volume = 55%, L lung volume = 45%

Front 74

During quiet inspiration,
diaphragm does _% of work,
intercostals _%

Back 74

During quiet inspiration,
diaphragm does 80%, intercostals 20%

Front 75

Parietal pleura produces _-_ L of pleural fluid/day
-cleared by _

Back 75

Parietal pleura produces 1-2 L of pleural fluid/day
-cleared by lymphatics in visceral pleura

Front 76

Lung cancer staging:
T1 is <_ cm

Back 76

Lung cancer staging:
-T1 < 3cm; T2 >3 cm
T3 =invades chest wall, pericardium, diaphragm, <2cm from carina
T4 = unresectable = mediastinum, heart, great vessels, esophagus, trachea, vertebrae, malignant effusion

Front 77

Lung cancer staging:
T3 is __

Back 77

Lung cancer staging:
-T1 < 3cm; T2 >3 cm
T3 =invades chest wall, pericardium, diaphragm, <2cm from carina
T4 = unresectable = mediastinum, heart, great vessels, esophagus, trachea, vertebrae, malignant effusion

Front 78

A 62-year-old, asymptomatic woman with a 60-pack-year smoking history presents with a new, 2x2-cm nodule in the left lower lobe of the lung not seen on a chest x-ray two years ago. A thorough history and physical examination is otherwise normal. The next step in management should be _

Back 78

lobectomy

solitary pulmonary nodule (SPN) or coin lesion is a mass in the lung smaller than 3 centimeters in diameter. It can be an incidental finding found in up to 0.2% of chest X-rays[1] and around 1% of CT scans. most commonly represents a benign tumor such as a granuloma or hamartoma, but in around 20% of cases it represents a malignant cancer. 10 to 20% of patients with lung cancer are diagnosed in this way

Front 79

Pt presents c/ 3 cm RLL mass on CT chest, found to be adenoca
-Mediastinoscopy: R paratracheal node (+)
-Next step = _

Back 79

Mediastinoscopy:
-Paratracheal nodes = N2 => unresectable
-Must do chemo-XRT
-Some protocols allow resection of primary tumor following chemo-XRT + mediastinal LN dissection if good response

Front 80

Lung cancer with R mediastinal lymphadenopathy -
where is the cancer?

Back 80

L lung can drain to R mediastinum
(L -> R like reading)

Front 81

During mediastinoscopy, look out for 4 things on the left..

Back 81

Mediastinoscopy:
-Left side: RLN, esophagus, aorta, main PA
-Right side: azygous, SVC
-Anterior: innominate vein, innominate artery, R PA

Front 82

During mediastinoscopy, look out for 2 things on the right..

Back 82

Mediastinoscopy:
-Left side: RLN, esophagus, aorta, main PA
-Right side: azygous, SVC
-Anterior: innominate vein, innominate artery, R PA

Front 83

During mediastinoscopy, look out for 3 things anteriorly..

Back 83

Mediastinoscopy:
-Left side: RLN, esophagus, aorta, main PA
-Right side: azygous, SVC
-Anterior: innominate vein, innominate artery, R PA

Front 84

Patient c/ myasthenia gravis c/o progressive sx despite optimal medical tx (steroids, plasmapheresis, Tensilon)
-Appropriate management is _

Back 84

Myasthenia gravis:
-Fatigue, weakness, diplopia, ptosis
-Ab's to acetylcholine R's
-Tx: anticholinesterase meds
-80% improve after thymectomy
-Getting worse despite optimal medical tx (steroids, plasmapheresis, Tensilon) =>
THYMECTOMY (even if thymus is normal or hypotrophic)
-10% of myasthenia gravis pts have thymomas, but 50% of pts c/ thymomas have myasthenia gravis

Front 85

Pt presents c/ neck mass and c/o fatigue and double vision
-Suspect _
-Tx is _

Back 85

Myasthenia gravis:
-Fatigue, weakness, diplopia, ptosis
-Ab's to acetylcholine R's
-Tx: anticholinesterase meds
-80% improve after thymectomy
-Getting worse despite optimal medical tx (steroids, plasmapheresis, Tensilon) =>
THYMECTOMY (even if thymus is normal or hypotrophic)
-10% of myasthenia gravis pts have thymomas, but 50% of pts c/ thymomas have myasthenia gravis

Front 86

_ = #1 determinant of myocardial O2 consumption

Back 86

WALL TENSION = #1 determinant of myocardial O2 consumption

Front 87

What non-small cell lung ca is known for higher local recurrence rates?

Back 87

Squamous cell ca:
-Usually central
-Higher rates of LOCAL RECURRENCE
-Paraneoplastic syn: PTH-rp release

Front 88

what is treatment of Paget von Schrotter's disease?

Back 88

Paget von Schrotter's dz = acute SCV thrombosis after repetitive activity, e.g. pitchers
-Tx: THROMBOLYTIC to open the vein -> usually proceed to 1st rib resection during that hospitalization

Front 89

Cachetic pt presents c/ claw hand
-Suspect _
-Mechanism is _
-Tx is _

Back 89

Brachial plexus invasion by pancoast tumor = superior sulcus tumor
-ULNAR nerve sx most commonly
-Superior sulcus tumors that invade the sympathetic ganglia only or just the lowest root of the brachial plexus can be resected

Front 90

Pancoast tumor:
-involves sympathetic chain (Horner's syndrome) and/or _ nerve

Back 90

Pancoast tumor:
-involves sympathetic chain @ T1 (Horner's syndrome) and/or ulnar nerve

Front 91

indications for resection of pancoast tumor

Back 91

Pancoast tumor can be resected if:
- invading only the sympathetic chain ganglia OR
-only the lowest nerve root of the brachial plexus

Front 92

paraesophageal hernia:
-Tx is _

Back 92

paraesophageal hernia:
-always operate 2/2 risk of incarceration, strangulation

Front 93

PDA: operative indication

Back 93

PDA:
operate (by L thoracotomy) if not closed by 6 months with indomethacin

- L to R shunt
- use PGE1 to keep it open if transposition of great vessels
-

Front 94

Pre-op PFTs: required FEV1s
>_L for pneumonectomy
>_L for lobectomy
>_L for wedge
-need post-op predicted FEV1>_

Back 94

Pre-op PFTs: required FEV1s
>2L for pneumonectomy
>1L for lobectomy
>0.6L for wedge
-need post-op predicted FEV1> 800 cc

Front 95

Pulm fx testing before lung resection:
-Need predicted post-op FEV1 >_
(or ar least _% of predicted value)
-If it’s close, get a _ to determine _

Back 95

Pre-op pulm fx testing:
-Need predicted post-op FEV1 of at least 800 cc
(or ar least 40% of predicted value)
-If it’s close, get V/Q scan (use the perfusion portion) to determine contribution of that lung portion to overall FEV1 (if low, may still be able to resect)
-R lung 55%, L lung 45%

Front 96

Pulm fx testing before lung resection:
-Need predicted post-op DLCO>_-_ mL/min/mmHg CO
(at least _% of predicted value)

Back 96

Pulm fx testing before lung resection:
-Need predicted post-op DLCO >11-12 mL/min/mmHg CO
(at least 50% of predicted value)

(this # depends on pulm capillary surface area, Hgb content, alveolar architecture)

Front 97

Phrenic nerve runs anterior or posterior to hilum?

Back 97

Phrenic nerve runs ANTERIOR to hilum
-Also anterior to the anterior scalene

Front 98

Type _ pneumocytes do gas exchange

Back 98

Type 1 pneumocytes do gas exchange

Front 99

Type _ pneumocytes make surfactant

Back 99

Type 2 pneumocytes make surfactant

Front 100

To be a candidate for pneumonectomy, pt must have FEV-1 >_ cc to give a reasonable chance of not being ventilator-dependent
-Preduct this based on PFTs and test _

Back 100

To be a candidate for pneumonectomy, pt must have FEV-1 >800 cc to give a reasonable chance of not being ventilator-dependent
-R lung = 55% of ventilation
-L lung = 45% of ventilation
-Use PEFUSION portion of V/Q scan to predict (i.e. if pt has FEV1 1200 but L lung only gets 10% of pefusion, you can still remove the lung)

Front 101

How do you use a V/Q scan to predict pulmonary function following pneumonectomy

Back 101

To be a candidate for pneumonectomy, pt must have FEV-1 >800 cc to give a reasonable chance of not being ventilator-dependent
-R lung = 55% of ventilation
-L lung = 45% of ventilation
-Use PEFUSION portion of V/Q scan to predict (i.e. if pt has FEV1 1200 but L lung only gets 10% of pefusion, you can still remove the lung)

Front 102

What do the pores of Kahn do?

Back 102

Pores of Kahn direct air exchange b/w alveoli

Front 103

What are 3 things that cause pseudo-achalasia?

Back 103

Pseudo-achalasia:
-70% caused by esophageal or gastric malignancy
-30% caused by strictures

-If pt presents c/ dysphyagia and barium swallow shows distal tapering + failure of LES relaxation, must do EGD to r/o pseudoachalasia

Front 104

How is PVR calaculated?

Back 104

(PA pressure - wedge) x 80 = CO x PVR

(delta P = flow x resistance)

Front 105

Pt c/ scleroderma presents c/ dysphagia
-Best therapy is _

Back 105

Scleroderma dysphagia;
-Loss of LES tone, strictures, fibrous replacement of smooth muscle -> dysphagia
-Tx: esophagectomy
-Nissen may be effective in some

Front 106

what lung cancer produces ACTH, ADH?

Back 106

Small cell lung cancer:
-20% of lung cancer neuroendocrine in origin. ACTH, ADH
->95% unresectable @ time of diagnosis, get CHEMO-XRT = CISPLATIN, ETOPOSIDE.
-Very poor prognosis. 50% 5-yr survival for T1N0M0
-Paraneoplastic syn: ACTH > ADH

Front 107

Paraneoplastic syndromes are most common in _ type of lung cancer

Back 107

Small cell lung cancer:
-20% of lung cancer neuroendocrine in origin. ACTH, ADH
->95% unresectable @ time of diagnosis, get CHEMO-XRT = CISPLATIN, ETOPOSIDE.
-Very poor prognosis. 50% 5-yr survival for T1N0M0
-Paraneoplastic syn: ACTH > ADH

Front 108

Small cell lung cancer:
-Typical therapy is _
-5-yr survival if T1N0M0 is _%
-<_% 5-yr survival overall

Back 108

Small cell lung cancer:
-20% of lung cancer neuroendocrine in origin. ACTH, ADH
->95% unresectable @ time of diagnosis, get CHEMO-XRT = CISPLATIN, ETOPOSIDE.
-Very poor prognosis. 50% 5-yr survival for T1N0M0
-Paraneoplastic syn: ACTH > ADH

Front 109

Spontaneous pneumothorax:
-_:1 male predilection
-__% recur; _% those recur again
-Indications for thoracoscopy

Back 109

Spontaneous pneumothorax:
-10:1 male predilection
-50% recur, then 75% of those recur again
-Do thoracoscopy for 2nd or continued air leak

Front 110

what lung cancer produces PTH-rp?

Back 110

Squamous cell ca:
-Usually central
-Higher rates of LOCAL RECURRENCE
-Paraneoplastic syn: PTH-rp release

Front 111

A 78 yo male with history of heavy smoking presents with a nodule on right lower lobe. Bronchoscopy reveals squamous cell carcinoma. The most likely symptom of this patient at presentation was

Back 111

The most common symptom at presentation is coughing (75%).
Other symptoms: dyspnea (60%), chest pain (50%), hemoptysis (30%), and weight loss (20-70%).

Front 112

Cachetic pt presents c/ swollen face, arms, hands.
-Suspect _
-Tx is _

Back 112

SVC syndrome:
-Swelling of upper extremities, face
-90% of cases are 2/2 lung cancer invading SVC = a T4 tumor = unresectable due to mediastinal invasion
-Tx = XRT (resection if a very small portion of SVC involved, e.g. incidental finding during thoracotomy)

Front 113

SVC syndrome:
-_% are 2/2 lung cancer
-Tx is _

Back 113

SVC syndrome:
-Swelling of upper extremities, face
-90% of cases are 2/2 lung cancer invading SVC = a T4 tumor = unresectable due to mediastinal invasion
-Tx = XRT (resection if a very small portion of SVC involved, e.g. incidental finding during thoracotomy)

Front 114

Swallowing function:
-_ initiates swallow, which elicits primary peristalsis
-_ then elicits secondary peristalsis.
-Sphincters are contracted @ rest
-Normal LES _ cm, tone _-_ mmHg

Back 114

Swallowing fx:
-Central input initiates swallow, which elicits primary peristalsis
-Distension then elicits secondary peristalsis.
-Sphincters are contracted @ rest
-Normal LES 4 cm, tone 15-25 mmHg

Front 115

Swallowing function:
-soft palate closes nasopharynx -> _ -> larynx closes -> __ -> pharyngeal contraction

Back 115

Swallowing fucntion:
-soft palate closes nasopharynx -> larynx up -> larynx closes -> UES relaxes -> pharyngeal contraction

Front 116

Takayasu arteritis:
-population is _
-involves vessels ...
-Diagnosed by _

Back 116

Takayasu arteritis:
-young female
-involves thoracic and ab aorta and PA
-Diagnosed by angio

Front 117

#1 congenital cyanotic heart disease is _

Back 117

Tetrology of Fallot:
-#1 congenital cyanotic heart defect
-Anterior + superior displacement of infundibular septum ->
1. malalignment VSD
2.) overriding aortic valve
3. Valvular + infundibular pulmonic stenosis
4.) LV outflow obstruction -> hypertrophic R ventricle

-Tx: beta blocker
-Operate if increased cyanosis
-Blalock-Taussig (BT) shunt can be used for palliation to delay repair

Front 118

what are the components of tetrology of fallot?

Back 118

The tetralogy of Fallot is the most common cyanotic heart defect.
VSD, RV hypertrophy, overriding aorta, and pulmonary stenosis.

Front 119

how does squatting help a Tet spell?

Back 119

The tetralogy of Fallot is the most common cyanotic heart defect.
VSD, RV hypertrophy, overriding aorta, and pulmonary stenosis.
-Squatting increases SVR -> L to R shunt -> increases pulm blood flow

Front 120

Thoracic duct runs along the _ side of chest until T_-T_ vertebra, then crosses over to the _ side

Back 120

Chylothorax;
-Milky white fluid c/ increases lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Fluid resistant to infection
-50% 2/2 trauma or iatrogenic injury
-50% 2/2 tumor (lymphoma most common, due to tumor burden in lymphatics)
-Thoracic duct enters chest on R c/ aorta @ T12 (i.e. damage during Ivor-Lewis) -> to L side @ T4-5 -> joins IJ/L SC junction
-Injury above T5 => L chylothorax
-Injury below T5 => R chylothorax
Tx: Conservative x 3-4 wks (chest tube, octreotide, low fat diet or TPN)
-Traumatic/ Iatrogenic injury + failure of conservative tx -> Ligation of thoracic duct on R side low in mediastinum 80% successful
-Malignant etiology + failure of conservative tx -> mechanical or talc pleurodesis (less successful)

Front 121

Thoracic duct injury:
-Tx = _

Back 121

Thoracic duct injury:
-Chylothorax = milky white fluid c/ increases lymphocytes and TAGs (>110 ml/ul); Sudan red stains fast
-Thoracic duct runs on R chest (i.e. damage during Ivor-Lewis) until T5-> to L side
-Injury above T5-6 => L chylothorax
-Injury below T5-6 => R chylothorax

-Tx: drainage/NPO x 2 wks
-if not resolved, then R thoracotomy + ligate duct

Front 122

What is the rate of symptom resolution adter surgery for thoracic outlet syndrome?

Back 122

60% success rate (complete symptom resolution) after surgery for throacic outlet syndrome

Front 123

during supra-clavicular approach for thoracic outlet syndrome surgery, phrenic nerve is located where in relation to the scalene muscles?

Back 123

Thoracic outlet syndrome:
-Brachial plexus (usually C8-T1) = most commonly affected
-PHRENIC NERVE RUNS ANTERIOR TO ANT SCALENE
-Long thoracic nerve is posterior to middle scalene
-Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene. SCV also over 1st rib but anterior to ant scalene.
-#1 anatomic abnormality = cervical rib
-Sx: NEURO (brachial plexus, esp. ULNAR nerve)> vascular sx (1-3%) affecting the back and neck.
-Adson's test: turn head to ipsilateral side -> compresses SCA -> decreases radial pulse
-Tinsel's test: tapping reproduces sx
-Dx: CXR, C spine x-ray, angiography if thought to be vascular etiology, EMG

Front 124

during supra-clavicular approach for thoracic outlet syndrome surgery, long thoracic is located where in relation to the scalene muscles?

Back 124

Thoracic outlet syndrome:
-Brachial plexus (usually C8-T1) = most commonly affected
-Phrenic nerve and SCV are anterior to anterior scalene.
-LONG THORACIC NERVE: POSTERIOR TO MIDDLE SCALENE
-Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene.
-#1 anatomic abnormality = CERVICAL RIB
-Sx: NEURO (brachial plexus, esp. ULNAR nerve)> vascular sx (1-3%) affecting the back and neck.
-Adson's test: turn head to ipsilateral side -> compresses SCA -> decreases radial pulse
-Tinsel's test: tapping reproduces sx
-Dx: CXR, C spine x-ray, angiography if thought to be vascular etiology, EMG

Front 125

Most common anatomic structure involved in thoracic outlet syndrome is _

Back 125

Thoracic outlet syndrome:
-BRACHIAL PLEXUS (usually C8-T1) = most commonly affected
-Phrenic nerve is anterior to anterior scalene
-Long thoracic nerve is posterior to middle scalene
-Branchial plexus + SCA go through a triangle = superior to 1st rib, posterior to ant scalene, anterior to middle scalene. SCV also over 1st rib but anterior to ant scalene.
-#1 anatomic abnormality = CERVICAL RIB
-Sx: NEURO (brachial plexus, esp. ULNAR nerve)> vascular sx (1-3%) affecting the back and neck.
-Adson's test: turn head to ipsilateral side -> compresses SCA -> decreases radial pulse
-Tinsel's test: tapping reproduces sx
-Dx: CXR, C spine x-ray, angiography if thought to be vascular etiology, EMG

Front 126

thoracic aorta aneurysm:
-Operative indications (2)

Back 126

Thoracic aortic aneurysm:
-operate if >6 cm or symptomatic
(more specifically: acutely symptomatic, 7 cm, 6 cm + Marfans, diameter 2x normal, rapid increase in size)

Front 127

Thymoma:
-do all need to be resected?
__ of myasthenia gravis patients have thymomas
-_% of myasthenia gravis patients experience improvement with resection

Back 127

Thymoma:
-indication for resection
-10% of myastenia gravis have thymomas
-resecting thymus (even if no thymoma) in M.G. experience improvement

Front 128

Tissue valves - 2 main indications

Back 128

Tissue valves:
-shorter lasting but no anticoag needed
-Population: may become pregnant, contraindication to coumadin, all mitral valves

Front 129

V/Q ratio is highest in the _ portion of lungs

Back 129

V/Q ratio:
-Highest @ apex (when pt seated): alveoli are most open @ apex, but gravity brings most of the blood to lower lobes
-When pts posterior for prolonged periods, anterior portions get more expanded and gravity brings blood posteriorly

Front 130

Vagus nerve runs anterior or posterior to hilum?

Back 130

Vagus nerve runs POSTERIOR to hilum

Front 131

#1 congenital heart defect is _

Back 131

VSD:
-#1 congenital heart defect
-L-R shunt
-50% close on their own, most by 6 mo
-Large VSDs cause sx after 4-6 wks, 2/2 decreased PVR
-Sx: CHF, FTT, tachypnea, tachycardia
-Medical tx: diuretics, digoxin

Repair if:
-FTT 2/2 CHF (#1 reason)
-Age 5 if doesn't close spontaneously
-PVR > 4-6 Woods units
-PVR > 10-12 Woods units = CONTRAINDICATION (use vasodilators to see if it is reversible -> if so, then repair)

Front 132

VSD:
-__% close on their own (most by __ months)
-operate if ...

Back 132

VSD:
-#1 congenital heart defect
-L-R shunt
-50% close on their own, most by 6 mo
-Large VSDs cause sx after 4-6 wks, 2/2 decreased PVR
-Sx: CHF, FTT, tachypnea, tachycardia
-Medical tx: diuretics, digoxin

Repair if:
-FTT 2/2 CHF (#1 reason)
-Age 5 if doesn't close spontaneously
-PVR > 4-6 Woods units
-PVR > 10-12 Woods units = CONTRAINDICATION (use vasodilators to see if it is reversible -> if so, then repair)

Front 133

Post-MI VSD:
-Day _-_
-_% of MIs
-__ murmur

Back 133

Post-MI VSD:
-Day 2-7
-2% of MIs
-Pan-systolic murmur

Front 134

62 year old male presents to ER one week after MI with dyspnea. Chest auscultation reveals a pan-systolic murmur. Transthoracic echocardiography is most likely to reveal what?

Back 134

Ventricular Septal Defects present day 2-7 after myocardial infarction (in 2% of MI's) as pan-systolic murmur heard during chest auscultation. Pan-systolic murmur heard after MI may also suggest mitral regurgitation from a ruptured papillary muscle.

Front 135

Woods units are …

Back 135

Woods units = units of vascular resistance frequently used by pediatric cardiologists

Front 136

Pt c/o dysphagia.
-Elevated UES pressure while swallowing

Back 136

Zenker's diverticulum:
-2/2 high UES (cricopharyngeus) pressure during swallowing (normal 70 mmHh @ rest, 15 mmHg in early swallow)
-False diverticulum, pulsion-type, (posterior) in Killian's traingle, b/w oblique + horizontal fibers of cricopharyngeus and pharyngeal constrictors
-Sx: upper esophageal dysphagia, choking, halitosis
-Dx: barium swallow, manometry
-Risk for perforation c/ EGD and Zenkers
-Tx: CRICOPHARYNGOMYOTOMY and diverticulectomy/pexy if possible
(diverticulum itself can be resected or suspended upward so that it drains into the esophagus)
-L cervical incision; leave drains in; esophagogram POD 1
-Almost all have hiatal hernia also many have GERD

Front 137

Zenker's diverticulum:
-2/2 ___
-Location
-Tx is _

Back 137

Zenker's diverticulum:
-2/2 high UES (cricopharyngeus) pressure during swallowing (normal 70 mmHh @ rest, 15 mmHg in early swallow)
-False diverticulum, pulsion-type, (posterior) in Killian's traingle, b/w oblique + horizontal fibers of cricopharyngeus and pharyngeal constrictors
-Sx: upper esophageal dysphagia, choking, halitosis
-Dx: barium swallow, manometry
-Risk for perforation c/ EGD and Zenkers
-Tx: CRICOPHARYNGOMYOTOMY and diverticulectomy/pexy if possible
(diverticulum itself can be resected or suspended upward so that it drains into the esophagus)
-L cervical incision; leave drains in; esophagogram POD 1
-Almost all have hiatal hernia also many have GERD

Front 138

Pt presents c/ neck mass and c/o fatigue and double vision
-Suspect _
-Tx is _

Back 138

Myasthenia gravis:
-Fatigue, weakness, diplopia, ptosis
-Ab's to acetylcholine R's
-Tx: anticholinesterase meds
-80% improve after thymectomy
-Getting worse despite optimal medical tx (steroids, plasmapheresis, Tensilon) =>
THYMECTOMY (even if thymus is normal or hypotrophic)
-10% of myasthenia gravis pts have thymomas, but 50% of pts c/ thymomas have myasthenia gravis