Aortic stenosis Echocardiography
TAVI - transcatheter aortic valve insertion
Aortic Surgery is advised to prevent cardiac failure
regurgitation The timing of surgery is determined by serial echocardiography
measurements demonstrating left ventricular dilatation
Acute cases : emergency ventilation and urgent surgery
Mitral stenosis Indication for surgery : echocardiographic calculated mitral valve below 1 cm
square
Percutaneous balloon valvuloplasty
Commissurotomy
Valve replacement
Mechanical mitral prosthesis thrombosis : emergency salvage valve
replacement or debridement
Mitral Indication for surgery : Left ventricular dilatation on chest X Ray and
regurgitation echocardiogram
Regurgitant valves are frequently repaired but valve replacement may be
required.
Acute regurgitation : emergency surgery
Tricuspid Tricuspid regurgitation : annuloplasty
valve disease Organic stenosis : replacement of the valve wit a biological prosthesis
Aortic Type B:
dissection Managed conservatively
Endovascular stent placement
Type A:
Emergency surgery : excision and replacement of the aorta containing the
entry point
Additional surgery to repair or replace the aortic valve / aortic arch /
descending aorta
Aortic Tests of respiratory system
aneurysms Coronary angiography with contrast CT or MRI angiogram
Transthoracic or transesophageal echocardiography
Aortic root or ascending aorta : woven dacron tube
Aortic annulo-ectasia : composite graft with aortic valve prosthesis
Aortic arch : complex
Descending aorta : suitable length graft
Pericardial Drained percutaneously through a catheter placed under echocardiographic
effusion guidance
Surgical drainage in cases of infection and malignancy
Chronic effusions : drained into left pleural cavity via open left lateral
thoracotomy
Minimal access videothoracoscopic procedure
Acute and malignant effusions : drained in peritoneal cavity via a short
epigastric incision
Fluid specimens are sent for culture and histology
Pericardial echocardiography
constriction Right heart catheterization with record of chamber pressures
CT or MRI
Surgery via median sternotomy to remove the fibrosed pericardium
Cardiac Surgical emergency
tamponade Prompt anterior thoracotomy and relief of the bloody tamponade
Digital control of penetrating injury until suitable suture is achieved
Major injuries to structures may require CPB
Atrial septal Closure is recommended when pulmonary to systemic flow ratio exceeds 2:1
defect Percutaneous or open closure depending on the size of the defect
Ventricular Operation is needed for large defects using a patch
septal defect
Patent ductus Indomethacin (Prostaglandin E1 inhibition)
arteriosus Clipping or division at left thoracotomy
Endovascular closure in case of older children
Coarctation of Balloon angioplasty
aorta Surgical correction : left subclavian artery is used as an onlay patch
Older children and adults : Dacron bypass graft
Tetralogy of Chest X Ray
Fallot ECG
Echocardiography
Closing VSD with a patch
Resection of the muscle bands contributing to the right ventricular outflow
obstruction
Enlarging right ventricular outflow tract with a patch placed across the
pulmonary valve annulus and along the pulmonary artery
If not fit for this procedure : a shunt is created in order to increase the
pulmonary blood flow
Bronchogenic Paraneoplastic syndromes :
carcinoma Ectopic hormone production (adrenocorticotrophic hormone (ACTH),
parathyroid hormone (PTH), antidiuretic hormone (ADH)) and a pain- ful
periosteal reaction affecting the joints and long bones, termed hypertrophic
pulmonary osteoarthropathy
Assessment for pulmonary resection
Fitness for resection
Staging
Resection
Staging :
Chest X Ray
Aspiration of pulmonary effusion
Contrast enhanced thoracic and upper abdominal CT
PET scan
Lymph nodes :
Mediastinoscopy
EUS
Mediastinotomy
Videothoracoscopy
Resection :
En bloc removal with surrounding parenchyma and local draining lymphatics
Lobectomy
Pneumonectomy
Involved anterior chest wall area is excised and replaced with synthetic
patch
Postoperative chemotherapy
Neoadjuvant preoperative induction chemotherapy to downstage tumor for
resection can be used
Metastatic lung biopsy
disease Palliative pleurodesis for the patients with pleural effusion
Other lung incidental chest X ray finding
tumors If malignant : local excision
If main bronchus is obstructed : lobectomy
Carcinoid tumors : lobectomy if atypical
Adenochondroma : incidental chest x ray finding
CT guided needle biopsy
Surgery if in doubt about malignancy
Mesothelioma Percutaneous pleural biopsy
Thoracoscopy
Open pleural biopsy
Light microscopy
Immunohistochemistry
Electron microscopy
Surgical excision of,
Parietal pleura
Lung
Diaphragm
Pericardium (pleuropneumonectomy)
Radiotherapy and chemotherapy
Therapy is directed at controlling the symptoms
Kaolin may be instilled
Mediastinum Mass lesions :
CT guided needle biopsy
Surgical biopsy using mediastinotomy, mediastinoscopy or
videothoracoscopy
Resection of the mediastinal lesions
Surgery is undertaken via median sternotomy for anterior lesions or a
thoracotomy for mid and posterior lesions
Infections
Pneumothorax Aspiration or insertion of chest drain connected to an underwater sesal into
the pleural space
Thoracoscopic surgery : lung is inspected and any bullae or blebs are
stapled
Pleurodesis
Bullectomy, abrasion or pleurectomy
Secondary pneumothorax :
Wait for 1 to 2 weeks for spontaneous resolution
Videothoracoscopy : bullae are closed by stapling
Kaolin mixed with local anesthesia can be inserted as a slurry up the drain
Emphysema Medical treatment :
Bronchodilators
Steroids
Transplantation is the definitive cure
Lung volume reduction surgery
Videothoracoscopic operation or median sternotomy
Interstitial lung transbronchial biopsy
disease Videothoracoscopic technique to excise a wedge of affected lung
Empyema Initial stages : low intercostal drainage
Later stages : formal surgical drainage
Videothoracoscopic techniques
Excision of 2 cm segment of rib over the lowest part of empyema and
suctioning and curetting the cavity clean
Elderly patients : simple open tube drain is left in situ for many months
Younger patients : open formal thoracotomy with decortication
Bronchiectasis Antibiotic therapy
Physiotherapy
Daily postural drainage
Evaluation by CT scan
Lobectomy in case one lobe damage
Chest wall Open operation
deformities Nuss procedure
Postoperative Lateral thoracotomy is more painful than median sternotomy
care Patients are kept in HDU for 24 to 48 hours following the surgery
Pain control
Management of secretions
Fluid management
Late management
Pain control :
Epidural catheter or
Morphine infusion supplemented by parenteral NSAIDs
Local intercostal nerve blocks
These are given through paravertebral catheters inserted at surgery
Management of secretions :
Patient should cough and clear secretions
Humidification of air to prevent the secretions from becoming viscous
Effective pain control
Physiotherapy
Excessive secretions are removed by :
Suction bronchoscopy under light general anesthesia
Mini tracheostomy tube inserted via cricothyroid membrane
Severe cases : ventilation and formal tracheostomy
Fluid management :
Fluid restriction for first 48 hours
Late management :
Subcutaneous heparin as prophylaxis
Drains are drawn when air leakage stops
Patients are mobilized as early as possible
Discharge :
Major open resection : 6-9 days
Videothoracoscopic procedures : 1-5 days
