Cardiothoracic

Cardiothoracic

LUNG CANCER

Incidence

50 deaths / 100,000 / year.

5 yr survival 1981-87 - 13%. 1950-54 - 6%.

Second to ischaemic heart disease as the most frequent cause of death.

Most common cancer in men, 2nd to breast cancer in women.

No. 1 cause of cancer death.

Male – female 2:1

90%  > 40 years.

Aetiology

Smoking

• Risk varies with type of tobacco, amount smoked, tar content
• Contain tumour initiator & carcinogen (eg. Polycyclic aromatic hydrocarbon, nitrosamine)
• Passive smokers have elevated biomakers of tobacco exposure

Environmental risk factors

• Arsenic, chromates, nickel, asbestos, silica, iron, coal 
• Organic chemicals: benzopyrene, vinyl chloride, chloromethyl ether  
• Miners, halothane workers 
• Diesel exhaust, urban air pollution
• Smoking & occupational exposure have additive effect

Dietary factors

• Fruit & vegetables protective
• Retinoids inhibit tumour development

Preexisting lung disease- COAD, pulmonary fibrosis

Inheritance

Genetic alterations

Clinical Presentation

Cough (most common)

Dyspneoa

Wheeze

Haemoptysis

Unresolved pneumonia

Chest wall pain (poor  prognostic sign)

Pleural effusion

Local invasion of primary tumour

As a result of:

• Local invasion of primary  tumour
• Regional spread
• Distant metastasis
• Paraneoplastic syndrome

Regional spread	Distant metastasis
Pleural effusion Chest wall pain Malignant pericardial effusion Superior Vena Cava syndrome Horner’s syndrome Horseness Diaphragmatic paralysis Dysphagia	Adrenal gland involved in  50%. Bone 20%. Liver 40%. Brain 20%.

Paraneoplastic  syndrome

10% of patients

Example

Anorexia, cachexia, general  malaise, low grade pyrexia  -> Tumour necrosis factor, interleukin-1

ACTH, vasopressin -> small  cell lung CA

PTH -> squamous cell CA

Eaton-Lambert myasthenic  syndrome

Primary Investigations

Sputum Cytology.

CXR

Bronchoscopy.

CT thorax – high resolution.

PET scans.

Percutaneous needle biopsy

No satisfactory tumour marker.

Staging investigation

Mediastinoscopy

Thoracoscopy (direct /  video assisted)

Metastatic work up

• CT chest, abdomen, brain
• Isotope bone scan
• Liver function test, Bone  profile (esp Alk phos)

Pathology

Non-small cell lung cancer

• Adenocarcinoma
• Squamous cell carcinoma
• Large cell (undifferentiated)  carcinoma
• Mixed

Small cell lung cancer

• Spindle or oat shaped cells, dense nuclei, sparse cytoplasm .
• Early metastases.

Adenocarcinoma

• Less common primary (5-15%).
• Variable degrees of glandular differentiation.
• Peripherally located.
• Lymph node metastasis common
• Commoner in women.

Squamous cell carcinoma

• Most common primary (40-70%).
• Centrally located.
• More common in men.
• Keratin pearls, bridging.
• Most likely to produce malignant cells in sputum cytology.

Large Cell

• 5-10% of lung  malignancies.
• Absence of glands or  keratinization.
• Peripherally located.
• Poorly differentiated, often  cavitated.
• Rapid growth.
• Early metastasis to  mediastinum and brain.

Pulmonary Metastases From Other Primary Tumour

Kidney.

Prostate.

Breast.

Connective tissue.

Testes.

Peripheral location.

Staging

Surgical Treatment

1933 - Graham and Singer -  First pneumonectomy for  carcinoma 

1950 - Churchill -  Lobectomy is effective for  Ca and safer than  pneumonectomy 

Jensik - Wedge or  segmentectomy   

Only 10% of patients with  lung cancer are surgical  candidates.

50% of surgical patients  have mediastinal N2  disease.

Preoperative Assessment

Radiology.

Pulmonary Function Tests.

Predictors of post op  mortality & morbidity

• CVS disease
• Pulmonary disease
• General med. Condition
  • Age > 70 years
  • Nutritional status
  • Associated chronic disease (eg. Diabetes)
  • Immunosuppresion
• Extent of resection
• Psychosocial factors

Inoperable

Pre-op PFT’s unfavourable.

Distant metastases (absolute)

Malignant pleural effusion (absolute)

Superior vena caval syndrome

Horners syndrome

Vocal cord paralysis

Phrenic nerve paralysis

Small Cell Carcinoma

Thoracotomy

Anatomy

Surgical Procedure

Radiotherapy

• Local Control.
• Pre-operative downstaging.
• Resection margins.
• Complications: radiation  pneumonitis  & Fibrosis.

Chemotherapy

• Experimental in Non Small  Cell Ca
• Small Cell Lung Ca –  increases life expectancy  from 5 months to 10.
• Eg. Mitomycin C,  ifosfamide, cisplatin,  vindesine, vinblastine.
• Induction (neoadjuvant)  therapy before surgery /  radiotherapy

Prognosis & Outcome

Overall 13% at 5 years.

SCLC < 5% at 5 years.

NSCLC

Stage IA,B               resected              60-85% 5 year survival

Stage IIA,B resected              40-60%

Stage IIIA               resected              30-40%

                            unresected              10-40%

Stage IIIB                                          <10%

Stage IV                                          <5%

Screening

CXR / MRI.

Sputum cytology.

Bronchoscopy.

Low yield (53/10,040  smokers)

PNEUMOTHORAX

Definition- injury to the lung  resulting in release of air into  the intrapleural space(between  the parietal and visceral pleura)

Classification

Primary spontaneous

• Tall thin people
• Age; 20-30 years old
• Smokers- occurrence increases directly with the number of cigarettes smoked per day
• Familial
• Presentation
  • Sudden onset SOB
  • Associated with chest pain

Secondary spontaneous

Underlying pulmonary  pathology

• Most commonly seen in COPD  patients
• Other causes include
  • Sarcoidosis
  • Tuberculosis
  • Cystic fibrosis
  • Malignancy
  • Idiopathic pulmonary fibrosis

Traumatic  pneumothorax

• Penetrating versus blunt chest  trauma

Tension pneumothorax

• Surgical emergency
• Definition-a build up of positive  pressure within the hemithorax- mediastinal shift.
• One way valve mechanism- air  enters alveoli but can’t escape  as the lung tissue collapses  around the hole in the pleura.

Examination

Decreased or absent breath sounds on affected side

Hyperresonance

Decreased tactile fremitus

Hypotension

Tachycardia>130

Tachypnoea

Cyanosis

Distended jugular venous pulsation

Tracheal deviation to contralateral side

Mediastinal shift

• Pressure on unaffected lung  interferes with gas exchange  leading to hypoxaemia
• Pressure on the heart reduces  venous return to the heart  reducing cardiac output.
• Leads to cardiorespiratory  failure

Investigations

• Chest X ray- should never be  performed when suspecting   tension pneumothorax
• ABG-hypoxaemia
• Imaging to distinguish Bullae at  apex from pnemothotax- in  emergency setting U/S or CT if  not an emergency

Management of  spontaneous  pneumothorax

Observation with follow up X- ray

Tube thoracostomy

Immediately insert a large bore  cannula into 2nd intercostal  space in midclavicular line

Hissing sound will be heard

Follow by inserting a chest  drain

Insertion of chest drain

• NB remember surgical  principles ie aseptic technique
• Paint with Bethadine
• Drape the surrounding area
• Triangle of safety is

1) anterior to the midaxillary line

2) above the level of the nipple

3)below and lateral to the pec major

• 5th intercostal space in  midaxillary line
• Sharp dissection of skin
• Blunt dissection through the  remaining tissue as far as the  parietal pleura
• The tract should be just above  the lower rib to avoid the  neurovascular bundle aiming  toward the apex.
• Insert finger into cavity and use  this to guide the trocar
• Remove the trocar and the tube is carefully and securely positioned using a purse string suture.
• Tube is then connected to an underwater seal and bubbling of the water is observed.
• Request a chest x ray to determine correct positioning of the tube and reinflation of the lung

Definitive surgical management

Indications

Recurrent pneumothorax for any  reason

Patients with

high risk occupations eg pilots,  divers.

Surgical options

Pleurodesis- tube thoracostomy  with preferred agent being talc

Thorocotomy with pleurectomy

VATS- video assisted thorascopic  surgical biopsy with talc  insufflation

THORACIC TRAUMA

Epidemiology

Thoracic Trauma Mortality 10  %.

Cause of  1 in 4 trauma deaths.

< 10 % of blunt trauma need  thoracotomy.

15 – 30 % of penetrating  trauma need thoracotomy.

Pathology

Hypoxia.

Hypercarbia.

Acidosis.

Initial Assessment

Primary Survey

Resuscitation of vital function

Detailed secondary survey

Definitive care

Airway

Foreign object

Laryngeal trauma.

Maxillofacial Trauma.

Sternoclavicular posterior dislocation.

Management

• Oropharyngeal Airway
• Endotracheal intubation.
• Tracheostomy.

Breathing

Tension Pneumothorax	Open Pneumothorax	Flail Chest	Haemothorax
One-way valve air leak Clinical diagnosis – do not wait for X ray Needle decompression Chest drain	Sucking wound. Close / Occlude defect. Chest drain.	2 or more fractures in the same rib. Mobile segment. Associated damage to underlying lung. Ventilation / analgesia.	More common with penetrating trauma Chest drain Operate  if - > 1500ml drained immediately or 200ml/hr for 2 – 4 hours

Circulation

Massive Haemothorax

Cardiac Tamponade

• Penetrating injury
• Beck’s triad
• Pericardiocentesis

Mgt: Volume replacement

Secondary Survey

Simple pneumothorax.

• Penetrating  or blunt injury.
• Rib / vertebral fracture.
• Lung laceration.
• Ventilation perfusion mismatch.
• Chest Drain
  • 4th-6th intercostal space
  • Anterior to mid-axillary line
  • Underwater Seal
  • Always if ventilated (GA / ITU)

Hemothorax.

• Lung laceration / IMA / Intercostal.
• Usually  self limiting.
• Large bore drain.
• Drain to monitor / prevent empyema

Pulmonary contusion.

• Hypoxia.
• May require ventilation.

Tracheobronchial injury.

• Rare.
• One inch from carina.
• Hemoptyosis, subcutaneous emphysema.
• Pneumothorax with persistent leak.
• Bronchoscopy.
• Operative treatment.

Blunt cardiac injury.

• Myocardial contusion.
• Chamber disruption.
• Valve disruption.
• Arrhythmia / Low CO / MI.
• ECG monitoring x 24 hours.

Aortic disruption.

• Site: ligamentum arteriosum.
• Contained haematoma.
• Non-specific symptoms / signs.
• History.
• CXR.
• Contrast / CT angiogram.

Diaphragmatic injury.

• Left > right.
• Herniation of abdominal viscera.
• Respiratory compromise / GI strangulation.

Bony Injury

• Ribs – common – pain / pneumo-hemothorax.
• Severe: scapula / 1/2nd rib / sternum.
• More worrying if in young – should be flexible.
• Management  -  analgesia.

Oesophagus

• Mostly penetrating.
• Boerhaave’s type – intra-abdominal pressure.
• Mediastinitis & empyema.

Projectiles & Stabbing

• Sharp instrument
• Gunshot wound increasingly  more common
• Shotgun / Rifle

Indications for Thoracotomy

Severe/Continuing Haemorrhage

Massive Air Leak

Massive Haemoptysis

Cardiac Tamponade

Open Pneumothorax

Pleural Contamination/Retained Foreign Body

Ruptured Aorta

Ruptured Diaphragm

Ruptured Oesophagus

Valvular or Septal Cardiac Injury

A/E thoracotomy

Indications:

Must have rhythm.

Must have penetrating trauma.

Must have  been witnessed alive.

MITRAL REFURGITATION

1st  described by Barlows, 1960s

Myxomatous degeneration  commonest cause

Leaflet thickening, annular  dilatation, chordal elongation

Other causes: Rheumatic,  Ischaemic

Pathology & Natural History

Affect 2-6% of population

Leads to LA+LV enlargement

A.Fib

• Complication:
• Congestive cardiac failure
• Pulmonary hypertension
• Sudden death
• Infective endocarditis
• CVA

Clinical Feature

History

              - asymptomatic

              - dyspnoea

              - congestive cardiac failure

Physical Examination

• systolic murmur radiates to axilla

Investigation

ECG

AFib, Left axis deviation, BBB

CXR

LA + LV enlargement

Echocardiography

• Quantify regurgitation
• Direction of jet indicates leaflet prolapse

Coronary Angiography

• Quantify regurgitation
• Assessment of pulmonary hypertension
• Coronary anatomy

Surgery

Indications

Symptomatic MR

Deteriorating LV function

Increasing LV dimension

Atrial fibrillation / pulmonary  hypertension

Surgical Options

Reconstruction

Replacement

Mitral Anatomy

Mitral Reconstruction  Technique

• Resection of leaflet
• Ring Annulopolasty
• Sliding Plasty
• Chordal Shortening
• Chordal Transfer
• Chordal Replacement with artificial chordae

Benefit of Mitral  Reconstruction

1st  described by Lillehei,1957

Made popular by Carpentier “The  French Correction”, 1983

Distinct survival advantage over  Mitral Replacement

Preservation of subvalvular  apparatus

ARRHYTHMIA SURGERY

Most common arrythmia surgery ->  Maze procedure for Atrial Fibrillation

James L.Cox 1987

Pathophysiology

• Arrythmogenic foci around pulmonary  vein
• Macroreentrant circuit

Maze procedure

Options

Cut & sew

Alternative energy source

• Radiofrequency
• Microwave
• Cryoenergy

Results

70-90% conversion rate- Paroxysmal A.Fib has better  conversion rate

Mortality 0.8-4%- Related to concomitant procedure

HEART TRANSPLANTATION

History

1st heart transplant -1967

Ireland – 1985

Most successful treatment for end stage heart failure

239 transplant to date

Indication

Systolic heart failure

Severe coronary disease not amenable to CABG/PTCA

Intractable arrythmia

Hypertrophic cardiomyopathy

Congenital heart disease

Recipient Selection

Age < 65

Healthy apart from cardiac disease

Healthy mental state

Stable social circumstances

Compliant with medical advice

Donor Selection

Age < 55

Absence of:

• Prolonged cardiac arrest
• Prolonged severe hypotension
• Preexisting cardiac disease
• Intracardiac drug injection
• Severe chest trauma with evidence of cardiac injury
• Septicemia
• Extracerebral malignancy
• Positive serologies for human immunodeficiency virus, hepatitis B, or hepatitis C
• Hemodynamic stability without high-dose inotropic support (<20 µg/kg/min dopamine)

Chain of Event

Transplanted centre informed about potential donor

Retrieval team transported to donor hospital

Organ assessment & retrieval

Organ transported back to transplant centre

Ischaemic time < 4 hr

Donor Cardiectomy

Allograft Preparation

Heart Implantation

Post op care in ITU

Post op

ITU invasive monitoring +  Ventilation

Cardiac Pacing

Cardiovascular support with  inotropes, IABP

Immunosuppresion

Endomyocardial biopsy

Immunosuppresion drug

Induction therapy- OKT3, ATG

Calcineurin inhibitor- Cyclosporin, Tacrolimus

Antiproliferative- Mycophenolate Mofetil, Azathioprine

Steroid

Newer agent- IL2 blocker (Basilximab)

Complication

Rejection- Hyperacute, Acute, Chronic graft  vasculopathy

Malignancy- Related to immunosuppresion

Renal Failure- Related to immunosuppresion

CORONARY ARTERY BYPASS GRAFT (CABG)

Indications: Symptomatic  angina,  not  relieved  by  medical  treatment.

CASS  study [1] compared medical therapy to CABG  showing surgical patients had less pain, fewer activity limitations and objective increase in exercise tolerance.

[1] CASS Circulation 1983; 68: 951

CABG - Indications

• Left main stem stenosis. Stenosis > 50 % is a  predictor of poor response to medical therapy. PTCA too  hazardous
• 3 vessels  disease with impaired ventricular function.
• 2 vessels  including  proximal  disease  in the  LAD or  any  2 in  a diabetic.
• Complication  from  PTCA.

Pre-operative Risk

Preoperative risk assessment

Strongest single indicator of outcome is  ejection fraction.

EuroSCORE [1].

[1] Nashef SAM, et al. Eur J Cardiothoracic Surg  1999; 16: 9

CABG Procedure

Median sternotomy

Harvesting conduits

Establish cardiopulmonary bypass

Anastomosis of bypass conduits

Weaning from CPB

ITU recovery

Harvesting Grafts

Veins graft: 

• Reversed  autologuous  saphenous  vein

Arterial

• Internal  mammary  redirection
• Radial artery
• Inferior epigastric (uncommon)
• Gastroepiploic artery (uncommon)

Going on Cardiopul.  Bypass

Anticoagulate

Cannulation to asc. aorta + r.atrium/  v.c.

Arrest heart – cardioplegia

Cool

Ventilation stopped

Minimise complications

Coming off Cardiopul  Bypass

Re-warm

Heart rate

Reverse anticoagulation

Pump function

ITU

Monitoring

Ventilatory support

Inotropic support

Fluid management

Mediastinal drainage

Outcome

85-90 %  improve in symptoms and  do not  need  medication.

CABG  improves  myocardial function, and improves CHF related to ischaemic  cardiomyopathy.

CABG  does not prevent ventricular arrhythmia.

Outcome II

Internal  mammary artery:  90 %  patency  at  10 years.

Radial artery: 80 – 90% patency at 10 years

Saphenous vein graft:  50 - 70 %  patency   at  10  years.

PTCA of stenotic vessel: 60 % patency at 6 months.

PTCA of occluded vessel  40 % patency at 6 months.

CABG v PTCA

Similar procedural related mortality.

CABG longer hospital stay.

Half of PTCA group require re-intervention in 3 years.

Complications

Operative  mortality  1-4 % in 1980s, now  2-5 % as patient population has  changed

CVA 2 %

Renal failure

Arrhythmia

Low cardiac output syndrome

Aortic Valve Disease

Valve Disease

Congenital.

Acquired

Rheumatic

Degenerative

Endocarditis

Ischaemic

Cystic Medial Necrosis / Marfan’s

Aortic Stenosis

Dyspnea, angina, syncope in 1/3

Angina more common with CAD

Severe AS = LV to Ao gradient greater than 50 mmHg or aortic valve area less than 1.2 cm2/M2

Aortic Incompetence

Aortic Incompetence

CHF symptoms, angina 1/4, syncope rare

Severe AI = LV enlargement, calculated LV end systolic pressure greater than 50mm Hg, EF less than 40%, calculated fibre shortening less than 0.6 cm/sec

Aortic Valve Replacement Prosthetic Options

ProstheticOptions

Complications

Operative  complications

Infection

Thrombosis

Haemolysis

Mechanical failure

Anticoagulation

Warfarin

Aspirin

Target INR.

Survival

5 years - 75%10 years - 60%15 years - 40%

Mode of death· Early due to CHF, haemorrhage, infection, CVA· Sudden - 20%· Device related - 20%