Some notes in Cardiothoracic surgery. These notes were published in 2019. You can download the file from: - Mediafire: http://www.mediafire.com/file/zrxenwq4tjdnhsj/file

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Cardiothoracic Surgery Q&A 2019
Kareem Alnakeeb
Video-assisted thoracoscopic surgery (VATS)
 VATS set consists of:
1. Telescope
2. Camera head & camera source
3. Light cable & light source
4. Screen
5. Instruments: long, double joint instruments
 Indications:
- Biopsies from pleura, lung, mediastinum or diaphragm
- Decortication
- Bullectomy and blebectomy
- Pulmonary resection, wedge resection or lobectomy
- Thymectomy in cases of thymic tumors & myasthenia gravis.
- Resection of pulmonary and mediastinal tumors.
- Repair of diaphragmatic eventration and hernia
- Post-traumatic exploration in only vitally stable patient
 Contraindications:
- Lack of well-prepared VATS set and instruments.
- Untrained surgeon
- Unstable patient
- Inability to tolerate single lung ventilation.
- Inability to do a complete job as open thoracotomy (ex, complete oncological clearance).
- Extensive adhesions (in early learning curve), possible with experienced surgeon.
 When to convert to open thoracotomy?
- Emergent complication: Uncontrollable bleeding.
- Technical problems: (Equipment or stapler malfunction - Poor visualization).
- Anatomical or oncological problems:
• Extensive adhesions with inability to further progress
• Inability to do a complete job as open thoracotomy
(ex, complete oncological clearance or if you need to palpate).
• Accidentally discovered lesion which is beyond surgeon’s experience to deal with
thoracoscopically.

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Cardiothoracic Surgery Q&A 2019
Kareem Alnakeeb
 Advantages:
- Cosmetic wounds.
- Less postoperative pain
- Less postoperative hospital stay
- Less incidence of wound infection
- Faster return to normal life
 Disadvantages:
- Cost (staplers)
- Difficult control in cases of emergent bleeding
 you have to convert to open thoracotomy if uncontrolled
- Relatively longer operative time
 shortened with advanced learning curve
 Philosophy of minimally invasive cardiothoracic surgeries:
- Less pain
- Less blood transfusion
- Less Cardiopulmonary Bypass (CPB)
- Cosmetic wounds
 Types of pulmonary resection:
- Anatomic resection: (Pneumonectomy, Bilobectomy, Lobectomy, Segmentectomy)
- Non-anatomic resection: (wedge resection)
 Causes of pneumothorax:
1. Primary spontaneous
▪ Due to rupture of apical subpleural bleb or cysts.
▪ Occurs most frequently in tall, thin, young males and smokers.
2. Secondary spontaneous
▪ Due to diseased lung (eg, bullae in emphysema, infections).
3. Traumatic
▪ Caused by blunt (eg, rib fracture), penetrating (eg, gunshot), or iatrogenic
(eg, central line placement, lung biopsy, barotrauma due to mechanical
ventilation) trauma

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Cardiothoracic Surgery Q&A 2019
Kareem Alnakeeb
 Types of pneumothorax:
1. Simple (closed)
2. Open
3. Tension: Air enters pleural space but cannot exit. May lead to  intrathoracic pressure
 mediastinal displacement  kinking of IVC   venous return   cardiac output
 Lines of treatment of pneumothorax
- Observation (X-ray /6h)
- Aspiration
- Chest tube
- Exploration (Surgery or VATS)
 Median Sternotomy
Advantages: Disadvantages (Complications):
- Good exposure
- Easy
- Rapid
- Familiar to surgeon
- Dehiscence or bone fractures
- Infection (superficial or deep mediastinitis)
- Bleeding
- Disfiguring scar or keloid
- Infected sinus
- Painful stainless wire
 Most common Mediastinal masses:
Some pathologies (eg, lymphoma, lung cancer, abscess) can occur in any compartment,
but there are common associations:
Anterior: Thyroid, Thymic neoplasm, Teratoma, “Terrible” lymphoma.
Middle: Esophageal carcinoma, metastases, hiatal hernia, bronchogenic cysts.
Posterior: Neurogenic tumor (eg, neurofibroma), multiple myeloma
 Ideal prosthetic valve:
- Cheap
- Available
- Easy to implant
- Durable
- Inert
- Silent
- Not need long-life anticoagulation

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Cardiothoracic Surgery Q&A 2019
Kareem Alnakeeb
 Modalities of surgery for Mitral Valve Disease:
- Closed mitral valvotomy - Open mitral valvotomy Rarely used
- Mitral valve replacement - Mitral valve repair
Closed mitral valvotomy
Indications Contraindications
- Surface area of MV < 2 cm2
.
- Diastolic pressure gradient > 5 mmHg.
- Severe symptoms.
- Massive uncontrolled hemoptysis (urgent).
 The best valve for CMV is isolated pliable
non-calcific valve with doming leaflets.
- Calcific MS.
- Heavily fibrotic immobile leaflets.
- Incompetent valve.
- Left atrial thrombus.
- History of systemic embolization.
- Hemiplegia or paraplegia.
 Indications for open mitral valvotomy:
- Isolated mitral stenosis with:
o Left atrial thrombus.
o History of systemic embolization.
o Hemiplegia or paraplegia.
 Indications for mitral valve replacement:
- Calcific mitral stenosis.
- Extensive fibrotic immobile stenotic valve.
- Severe mitral incompetence.
- Native valve endocarditis.
- Prosthetic valve endocarditis.
- Stuck prosthetic valve.
 Indications for mitral valve repair:
- Severe mitral incompetence due to:
o Myxomatous degeneration of mitral valve.
o Floppy mitral valve.
o Ruptured chordeae.
o Elongated chordeae.
o Selected cases with limited valve calcification, rheumatic etiology, endocarditis.

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Cardiothoracic Surgery Q&A 2019
Kareem Alnakeeb
 Advantages of mitral valve repair:
- The original valve is preserved.
- No need for long-life anticoagulation.
- No hazards of thromboembolic complications.
- No hazards of mechanical complications of prosthetic valves.
- No hazards of calcification or degeneration of biological valves.
 Diaphragmatic Eventration:
- Def: all or part of the diaphragmatic muscle is replaced by fibroelastic tissue.
- Can be congenital or acquired
- Many patients are asymptomatic
- Can be seen incidentally on chest x ray & diagnosis is confirmed by fluoroscopy or US
- In infants the management depends on the extent of the respiratory distress,
often NO need to treatment
 Congenital diaphragmatic Hernia:
- due to failure of fusion of diaphragmatic components during development
- Types:
 Bochdalek hernia:
▪ Common (95%)
▪ Posterolateral
▪ May protrude into the posterior mediastinum
 Morgagni hernia:
▪ relatively uncommon
▪ anterior retrosternal or peristernal
▪ herniation of omentum and other abdominal contents into the thorax
manifest as a right cardiophrenic angle mass
- Diagnosis by: GI barium study or CT.
- Treatment is surgical in symptomatic cases.