Core Topics in Cardiothoracics

1. Aortic Stenosis
Epidemiology

Introduction How common is aortic stenosis

• Most common cardiac valve lesion in Western
Age Aortic Sclerosis Aortic Stenosis
populations
65-75 20% 1.3%
• The incidence is increasing- calcific aortic stenosis
is an age-related process and the population is 75-85 35% 2.4%
rapidly ageing
>85 48% 4%
• Accounts for approximately two-thirds of all
surgical valve procedures
• Transcatheter techniques have transformed our
approach to the management of aortic stenosis
• Surgical valve replacement remains 1st line for
patients at low to moderate operative risk
 Aetiology
Calcification of trileaflet valve Calcification of a bicuspid valve Rheumatic aortic stenosis

Diastole Systole Diastole Systole Diastole Systole

Clinical Features

Symptoms include
• Syncope 15%
• Angina 35%
• Dyspnoea 50%

Symptoms typically occur at age 50 to 70yrs with

degenerative disease of a bicuspid valve and >70yrs in
those with caicfication of a normal trileaflet valve
Clinical Features

Findings on examination include

Pulse
• Slow-rising (tardus) and low amplitude (parvus)

Palpation Systole Diastole

• Displaced apex
• Systolic thrill

Auscultation
• ESM, radiating to the carotids
• Other- soft A2, S4
Investigations

Electrocardiography Echocardiography
Severity of Aortic Stenosis

Grading of aortic stenosis on echo

Parameter Mild Moderate Severe

Jet Velocity (ms-1) <3.0 3.0 – 4.0 >4.0

Transvalvula gradient (mmHg) <25 25 – 50 >50

Valve area (cm2) >1.5 1.0 – 1.5 <1.0

Management

Who needs valve replacement?

• Severe symptomatic AS
• Severe AS with EF <50%
• Severe AS in patients undergoing CABG or other valve
surgery
Options for Management
Open Surgical aortic valve Trans-catheter aortic valve
replacement (AVR) implantation (TAVI)
• 1st line for low & intermediate risk patients • 1st line for inoperable patients

For high risk patients, discuss

the options of TAVI vs Open
AVR in the setting of a
multidisciplinary heart team
meeting
Open Surgical AVR

Bioprosthesis or tissue valve Metallic or mechanical valve

• Lifelong anticoagulation not required • Lifelong anticoagulation imperative
• Life of the valve limited to approx 15yrs • Valve has durability, will outlive the patient
Operative Anatomy

Opening incision of aortic root Exposure of leaflets

Operative Anatomy

Debridement and decalcination, sizing of aortic annulus, placement of sutures in sewing ring
Transcatheter Aortic Valve Implantation

Basics of TAVI
• Approach: percutaneous retrograde transarterial vs
antergrade transapical
• Device: balloon-expandable vs self-expandable
• Balloon aortic valvuloplasty is performed beforevalve
insertion to facilitate passage of the prosthesis
• Ventricular busrt pacing during deployment to reduce
transvalvular flow
• Complications
• Vascular injury including dissection
• Stroke
• Improper positioning
• Coronary obstruction
• Mitral valve injury
• Paravalvular regurgitation
• Annular and root rupture
2. Coronary Artery Bypass Grafting
Anatomy of the Coronary Circulation

Basic coronary artery anatomy Angiographic anatomy

• LAD – anterior part of septum, anterior
wall & apex of LV
• LCX – lateral, posterior and inferior
segments of LV
• RCA – RA, RV, post part of septum and
inferoposterior aspects of LV

Commonly occluded arteries: LAD > RCA > LCX

Indications for Revascularisation (PCI or
CABG)
Who should be considered for a revascularisation procedure?
1. Patients with activity-limiting symptoms despite
optimal medical therapy
2. Patients in certain scenarios where revascularisation
has a proven survival benefit regardless of symptoms
 e.g. multivessel CAD with reduced EF
CABG vs PCI

Left main coronary artery disease (>50% stenosis)

• CABG 1st line
• PCI acceptable alternative

Left main stem equivalent disease (>70% stenosis of prox LAD & prox LCX)
• Appears to behave similarly to true left main disease
• Managed in similar fashion
• Prognosis somewhat better
CABG vs PCI

Single vessel disease

• PCI preferred over CABG

Two and three vessel disease

• For patients with diabetes or complex anatomy -> preference for CAB

• Low complexity anatomy, no diabetes and preserved LV function -> either PCI or CBAG
SYNTAX Scoring

Applies to left main and three vessel disease…

• 1800 patients assigned to PCI or CABG,
with 5yrs follow-up. Conclusion:
• For patients with high and intermediate
SYNTAX scores, the rates of MAACE were
significantly higher in the PCI group
Other points to note about CABG
Off-pump CABG versus
traditional on-pump CABG Graft conduit recommendations
• On-pump is gold standard, accounts for • Left internal mammary artery (LIMA) to
80% of CABG procedures left anterior descending artery (LAD)
• Off-pump associated with less bleeding, • An arterial graft should not be used in the
less renal impairment and less RCA unless critical stenosis
neurocognitive dysfunction
• On-pump associated with better long-
term patency of anastomoses
Operative Anatomy

Internal mammary artery

Operative Anatomy

Great saphenous

Open Endoscopic
Operative Anatomy

Radial artery

Allen’s test
Operative Anatomy

Coronary anastomoses
• Distal anastomoses first
• Left internal mammary – left anterior
descending
• Venous graft to R circulation, unless
critical stenosis
• Construction of an anastomosis should
never impede native flow
Postoperative care

The postop CABG patient…

• Step down transfer from theatre to ICU to
CT HDU to ward
• Low cardiac output state; preload
augmentation coupled with afterload Intra-aortic balloon pump (IABP)
reduction
• Patients with radial artery graft started on
nitroglycerin +/- amlodipine
• Pain management; often in suprisingly little
pain
• Beta blockers, ACE-inhibitors, other
antihypertensives as needed

Swan-Ganz (PA) catheter

3. Lung Cancer
Epidemiology & Risk Factors

Epidemiology
• 1800 cases/yr in Ireland
• 2nd most common cause of cancer-related
deaths
• Increasing ratio of women to men

Risk factors
• Smoking
• Radon
• Asbestos
Clinical Features

Symptoms Signs
• Cough • Chest signs e.g. consolidation
• Haemopytsis • SVC obstruction
• Dyspnoea • Horner’s syndrome
• Weight loss • Phrenic nerve palsy
• Fatigue • Pleural effusion
• anorexia • Clubbing
• Pericarditis
• Paraneoplastic
Lung Cancer work-up
Three key steps in the workup;
1. Tissue
2. Stage
3. Pulmonary function
Lung Cancer work-up

Tissue diagnosis

CT-guided lung biopsy Endobronchial biopsy

Lung Cancer work-up

TNM Staging made easy

T1 – small tumor
T2 – larger tumor
T3 – involving removabale structures
T4 – involving irremovable structures

N1 – nodes in lung
N2 – nodes in ipsilateral mediastinum
N3 – nodes in contralateral mediastinum

M0 – no metastases
M1a – intrathoracic mets
M1b – distant mets

Red = no prospect of surgical cure

AJCC Staging of Lung Cancer, 7th ed, 2009
Lung Cancer work-up

Precise staging imperative

• CT Thorax and upper abdomen (all patients)
• PET (all surgical candidates)
• Bronchoscopy/ EBUS (all patients)
• MRI/ CT Brain (select patients)
Lung Cancer work-up

Pulmonary function
• Pre-op FEV1 > 2 litres indicates
pneumonectomy should be well tolerated
• Pre-op FEV1 > 1.5 litres indicates
lobectomy should be well tolerated
Operative anatomy

Approaches to lung resections

• Open
• VATS
Operative anatomy

Pulmonary surgical operations

• Lobectomy
• Pneumonectomy
• Segmental resection
• Wedge resection
Postoperative care of the thoracic patient
Postoperative care
• Early mobilisation
• Spirometry
• Analgesia

6hrs post-op 48hrs post-op 5days post-op 2wks post-op

4. Aortic Dissection
Aetiology

Risk Factors Pathogenesis

• Hypertension
• Marfan’s Syndrome
• Loeys-Dietz
• Ehlers-Danlos IV
• BAV
• FTAAD
• Turner syndrome
• Atherosclerosis
• Trauma
• Pregnancy
Clinical features
Signs & symptoms
• Severe ‘tearing’ pain
• Radiating to mid-back/ interscapular
• Radial & femoral pulse deficits
• Present with complications
Complications
• Aortic incompetance
• Stroke
• ACS
• Cardiac tamponade
• Renal impairment (anuric)
• NB anterior spinal artery
Imaging

CXR CT Angiogram
 Classification

Two classifications in common use

Stanford
• A – involvment of the aortic arch
• B – isolated involvement distal to origin of L subclavian

DeBakey
• I – ascending and descending
• II – ascending only
• III – isolated involvement distal to origin of L sublavian

Stanford A – 70% Stanford B – 30%

Management

Stanford A – usually warrants surgical repair Stanford B – usually conservative approach

Thank you!