Cardiothoracic Surgery

Terms	Definitions
Anteriorly, the thoracic cavity consists of...	Sternum and costal cartilages
Posteriorly, the thoracic cavity consists of...	Thoracic vertebrae
Laterally, the thoracic cavity consists of...	Ribs
Inferiorly, the thoracic cavity consists of...	Diaphragm
Sternum	Superior to inferior: Manubrium, body, and xiphoid process.
Ribs	Posteriorly attached to the thoracic vertebrae. There are 7 true ribs which are connected to the sternum by costal cartilage, 3 false ribs that are attached to the sternum indirectly by costal cartilage, and 2 false ribs (floating) ribs which don't attach to the sternum.
Three divisions of the thoracic cavity	Right pleural cavity, left pleural cavity, and the mediastinum.
Right pleural cavity	Consists of the right lung which has 3 lobes.
Left pleural cavity	Consists of the left lung which has 2 lobes.
Mediastinum	Consists of the esophagus, trachea, thymus, lymph nodes, and the heart with great vessels.
Pleura	A thin serous membrane that encloses the lung, composed of a single layer of mesothelial cells on top of a thin layer of connective tissue. It is divided into parietal and visceral pleura.
Parietal pleura	Lines the inner surface of the ribs, pericardium around the heart, and the superior surface of the diaphragm.
Visceral pleura	Covers outer surface of each lung.
Pleural space	Small space between the parietal and visceral pleura; contains serous fluid that prevents friction between the lungs and pleura during respiration.
Respiration	Principal muscles associated with inspiration are the diaphragm and external intercostals. Accessory muscles of inspiration are the sternocledomastoid and scalene muscles. Principal muscles associated with expiration are internal intercostals, external and internaloblique, transversus abdominis, and rectus abdominis.
The act of respiration	Diaphragm and external intercostals muscles contract --> ribs and sternum elevate --> size of thoracic cavity increases --> and pulmonary pressure decreases thus forcing air into the lungs.
Trachea	Extends from the larynx to bronchi. Formed by smooth muscle, hyaline cartilage (C-shaped rings to prevent the trachea from collapsing), and an inner wall composed of ciliated mucosa. It functions as a passageway for air to and from the lungs.
Bronchi	Trachea divides at the Carina into right and left bronchi. Bronchi are composed of smooth muscle and cartilaginous rings. The inner walls are lined with ciliated mucosa. Mucosa is composed of goblet cells.
Goblet cells of the respiratory system	Goblet cells secretions trap foreign particles; cilia pass the particles forward into the throat to be expelled as an aid in preventing respiratory tract infection.
Bronchial divisions	Bronchus enters the lung and divides into secondary lobar branches. Lobar branches divide into segmental bronchi. Segmental bronchi divide into bronchioles. Bronchioles end in alveolar ducts and alveoli.
Alveoli	Composed of simple squamous epithelium which exchange oxygen and carbon dioxide.
Lungs	Extend from just slightly below the clavicle to the diaphragm. They are composed of spongy elastic tissue The main organ of respiration.
Ancillary structures of the lungs	Bronchus, pulmonary artery, superior pulmonary vein, inferior pulmonary vein, and lymphatic vessels.
Hilum	Slight concave portion on medial side of each lung where the bronchus and other structures enter.
Left lung lobes	Superior and inferior lobes separated by a fissure.
Right lung lobes	Superior, middle, and inferior; each lobe is separated by a fissure.
Blood flow in the lungs	Blood low in O2 travels from the right ventricle of the heart through the left branch of the pulmonary artery to the left lung to be oxygenated. Blood travels in the same way to the right lung, except it travels through the right branch of the pulmonary artery. Oxygenated blood leaves the lungs through the pulmonary veins and enters the left atrium of the heart.
Bronchial arteries that arise form the aorta supply the__________,__________,and_________of the lungs.	bronchi, bronchioles, and tissue
Heart	A hollow muscular organ that's the size of a man's fist. The role is plays within the cardiovascular system is essential for the circulation of blood, which carries waste substances away from cells to excretory organs for elimination.
Where is the heart located?	Located within the medastinum, with two-thirds of the organ on the left side. It rests behind the body of the sternum and on the diaphragm. It lies diagonally, with the distal apex tapering to the left.
Pericardium	Protects the heart and prevents it from rubbing against the thoracic cavity wall. It consists of two parts; Fibrous pericardium and serous pericardium.
Fibrous pericardium	Outer layer, consists of white fibrous connective tissue, fits loosely around the heart and attaches to large blood vessels, but does not attach to the heart itself. It's inelastic and it protects the heart.
Serous pericardium	Is divided into 3 sections: The parietal layer, visceral layer, and the pericardial space
Parietal layer	Lines the inside of the fibrous pericardium
Visceral layer	Attaches to the surface of the heart.
Pericardial space	Is the space between the 2 layers that contains pericardial fluid which acts as a lubricant on the surfaces of the 2 layers reducing friction and allowing the heart to easily contract.
Heart wall	Composed of 3 layers; Epicardium, Myocardium, and the Endocardium.
Epicardium	The outer layer of the heart which provides protection and is composed of the visceral pericardium
Myocardium	Makes up the bulk of the heart wall; composed of specially constructed cardiac muscle cells that contract and force blood from the heart's chambers.
Endocardium	The inner lining of the heart wall, lines all of the heart's chambers and valves. The endocardium is composed of endothelial tissue, which consists of a single layer of flattened cells.
The chambers of the heart	The heart has 4 chambers; 2 atria and 2 ventricles.
Atria (atrium)	Upper chambers,they recieve blood from the veins of the body, have tinner walls than those of the ventricles, and are divided by the interatrial septum.
Ventricles.	Pump blood into the arteries leading away from the heart. Have a thicker myocardium than the atria. The right ventricle pumps blood to the lungs while the left ventricle pumps blood into the arteries that transport blood to all other regions of the body. They are divided by the inter-ventricular septum.
Heart valves	Atrioventricular valve (AV valve), Tricuspid, Pulmonary semilunar valve, Mitral valve, and Aortic semilunar valve.
AV valve	Located between each atrium and ventricle.
Tricuspid valve	Located between the right atrium and the right ventricle. It is named for it's 3 leaf-like cusps.
Pulmonary semilunar valve	Formed by 3 half-moon shaped cusps. The blood exits the right ventricle through the semilunar valve into the pulmonary artery to be transported to the lungs for oxygenation.
Mitral valve	Also called the bicuspid valve because it has 2 cusps. Allows blood to flow from the left atrium into the left ventricle. A pathological condition that can occur is Mitral valve regurgitation. The valve does not close, allowing blood to back flow into the atrium.
Aortic semilunar valve	Located at the base of the aorta, allowing blood to flow into the aorta.
Chordae tendineae	Fibrous cords that are attached to the cusps or valves on the ventricle side. They originate from papillary muscles that project outward from the walls of the myocardium. The cordae tendineae prevent the cusps of the valve from folding back into the atrium, which would cause incomplete closure of the valve and lead to regurgitation of the blood back into the atrium.
Blood flow through the heart	Right atrium receives deoxygenated blood from the superior vena cava-->Tricuspid valve opens allowing blood to flow into the right ventricle-->Pulmonary semilunar valve opens and blood enters pulmonary artery and travels to the lungs for oxygenation (which happens in the alveoli)-->Oxygenated blood returns to the heart through four pulmonary veins and enters the left atrium-->Atrial walls contract and the mitral valve opens causing blood to enter the left ventricle-->Left ventricle contracts, the mitral valve closes, the aortic semilunar valve opens, and blood enters the aorta for transport to the rest of the body.
Blood supply for the heart	Two coronary arteries originate from the ascending aorta: Right coronary artery and Left coronary artery.
Right coronary artery	Posterior descending artery: branches to both ventricles. Marginal artery: branches to right ventricle and right atrium.
Left coronary artery	Anterior descending artery: supplies blood to both ventricles. Circumflex artery: supplies blood to left ventricle and left atrium.
Cardiac cycle	Includes all pathological actions that occur during a single heartbeat. Each cardiac cycle pressure changes occur as the atria and ventricles contract and relax, and blood flows from areas of higher pressure to those of lower pressure.
Systole	Phase of contraction
Diastole	Phase of relaxation
Atria contract, forcing blood into the___________.	ventricles
Ventricles contract, forcing blood into the________that lead away from the heart.	vessels
The STAC assisting with an awake patient may help calm the patient by___________.	Explaining everything that will be done.
Which consideration may be more relevant to the elderly patient than to an adolescent?	Patient's skin condition.
When positioning the elderly patient, the team must be especially aware of_________.	loss of mobility in joints and increased risk of fractures and strains.
Which is a common physiological factor in the elderly?	decreased coronary artery blood flow.
Diagnostic imaging includes which of the following? A) History and physical examination B) Biopsy C) Direct visualization D) Radiography	D) Radiography
Plain radiographic films are used in the operating room to_____________.	ID the location of abnormalities and foreign bodies, locate lost sponges, sharps, or instruments, and aid in bone realignment and prosthesis placement.
An AP radiographic film is taken________.	from front to back.
Contrast medium is used to_________.	enhance visualization during diagnostic imaging procedures.
Fluoroscopy__________.	allows real time viewing of procedural events.
Angiography is used to______.	assess the cause and severity of peripheral vascular disease.
Angiography is________.	invasive, often performed in the cardiac cath lab, and performed under sterile conditions.
Cardiac catheterization permits___________.	evaluation of heart function, visualization of coronary arteries and cardiac chambers, and measurement of pressures within the cardiac chambers.
MRI is especially useful for imaging_________.	soft tissue.
Ultrasound involves the use of__________.	high-frequency sound waves.
Trans-esophageal echocardiography______________.	is a minimally invasive procedure.
Nuclear medicine studies are also referred to as_____________.	isotope scanning.
Blood collected from the patient for hematological studies may be___________.	arterial or venous.
The term staging refers to_____.	degree of tumor metastasis.
If a frozen section is indicated, the specimen must be_______.	Kept dry.
Thoracentesis is________.	removal of fluid from the pleural cavity.
Display and recording of the electrical activity of skeletal muscle is called_________.	EMG.
Arterial saturation of hemoglobin with oxygen is measured with the use of________.	pulse oxymetry.
What is the first priority of the STSR when an intraoperative X-ray is being taken?	Protect the sterile field from contamination.
Angiography catheters may be inserted through the ________vein.	femoral, subclavian, or jugular.
The Doppler probe can be utilized within the sterile field provided that_______.	is it covered with a sterile drape.
The pacemaker of the heart is referred to as the_______.	SA node.
The________receives unoxygenated blood from the body.	right atrium.
The______pumps blood into the pulmonary artery.	right ventricle.
The______pumps blood into the aorta.	left ventricle.
The coronary arteries arise from the_______.	aorta.
The coronary veins empty into the_______.	coronary sinus.
The_______artery supplies blood to the walls of the left atrium and left ventricle.	left anterior descending.
The valve between the left atrium and left ventricle is the________.	mitral.
The valve between the right atrium and right ventricle is the_______.	tricuspid.
Which structure is attached to the valvular cusps and prevent valves from swinging back into the atria?	chordae tendinea.
The pulmonary veins number________.	2
If red blood cells are higher than normal, the blood viscosity increases and the blood pressure__________.	increases.
Which structure prevents the trachea from collapsing?	hyaline cartilage.
The potential space between the visceral and parietal pleurae is the________.	pleural space.
The area between the alveoli and a respiratory bronchiole is the_________.	alveolar duct.
A short distance from its origin, each primary bronchus divides into_________.	lobar bronchi.
The microscopic air sacs clustered at the distal ends of the respiratory tubes are the_______.	alveoli
The main bronchi, pulmonary arteries, veins, and lymphatic vessels enter the lung on the medial surface through the_______.	hilum.
The right lung is divided into_____lobes.	three.
The heart lies______.	slightly to the left within the mediastinum.
The cardiac cycle refers to the events taking place_______.	during a single heart beat.
Systole refers to______.	the contraction phase of the heart.
Which division of the nervous system is responsible for slowing the heart rate?	Parasympathetic.
The inability of the lung to expand and accumulation of air in the pleural cavity is______.	pneumothorax.
What is the correct statement that describes a variation of an aneurysm?	A dissecting aneurysm involves the entire circumference of an artery.
An abnormal opening in the wall between the right and left lower chambers of the heart is known as a__________.	ventricular septal defect.
Cardiopulmonary bypass is required for which of the following procedures?	ASD.
Which instrument is preferred for removal of a foreign body in the bronchial tree of infants and children?	rigid bronchoscope.
Which of the following is not considered a sterile procedure? A) bronchoscopy B) mediastinoscopy C) thoracoscopy D) anterior mediastinoscopy	A) bronchoscopy
Which of the following statements is correct regarding a thoracoscopy? A) A thoracoscopy is a sterile procedure. B) CO 2 insufflation is necessary for visualization. C) Single-lumen endotracheal tubes are sufficient for intubation. D) The lumen on the affected side will not be collapsed for visualization.	A) A thoracoscopy is a sterile procedure.
Which portion is generally utilized for lobectomy?	Posterolateral
The prep parameters for a posterolateral thoracotomy are__________.	shoulder and arm to the iliac crest, as far lateral as possible.
Which intercostal space is entered for a thoracotomy?	5th
Which piece of equipment assumes the role of the heart and lungs while undergoing cardiopulmonary bypass?	pump oxygenator (heart and lung machine)
Which statement concerning cannulation for cardiopulmonary bypass is correct? A) Aortic cannulation is always performed after venous cannulation. B) Aortic cannulation is performed into the right atrium. C) Aortic cannulation is performed into the aorta. D) Venous cannulation is performed into the left atrium.	C) Aortic cannulation is performed into the aorta.
Which of the following techniques protects the heart on cardiopulmonary bypass from damage?	Hypothermia.
Which mechanical device is designed for circulatory support after cardiac procedures?	intra-aortic balloon pump.
Which hemostatic agent is placed on each side of the sternum after a median sternotomy to control bleeding. A) Avitene B) bone wax C) Surgicel D) thrombin	B) bone wax
The venous cannulation for cardiopulmonary bypass is placed in the_______and the arterial cannula is placed in the___________.	vena cavae, aortic root.
Which solution should never be found on a back table during a CABG?	Water.
An alternative to cannulation of the aortic root is cannulation of the_________.	femoral artery
Which of the following statements regarding cardiac pacemaker insertion is correct? A) This procedure must be done under general anesthesia. B) This procedure can be done under local anesthesia. C) The electrodes are placed in the left atrium. D) The electrodes are placed in the left ventricle.	B) This procedure can be done under local anesthesia.
"A closed system of blood vessels that transport blood away from the heart to the body's tissues and back to the heart" refers to the__________.	peripheral vascular system.
Microscopic vessels designed to exchange nutrients and wastes between blood and tissue fluid around the cells are known as________.	capillaries.
Which of the following accurately describes the layers of an artery from inner to outer layers? A) tunica media, tunica adventitia, tunica intima B) tunica intima, tunica media, tunica adventitia C) tunica adventitia, tunica media, tunica intima D) tunica intima, tunica adventitia, tunica media	B) tunica intima, tunica media, tunica adventitia
Which of the following statements accurately describes the characteristics of a vein? A) Veins carry oxygenated blood away from the heart. B) Veins have only two layers, the tunica intima, and the tunica adventitia. C) Venous lumens are typically narrower than arterial lumens. D) Veins have specialized structures called valves.	D) Veins have specialized structures called valves.
Which of the following statements concerning blood pressure is incorrect? A) Arterial BP is dependent upon factors such as blood volume, heart rate and strength of ventricular contraction. B) Venous BP is much higher than arterial BP. C) The pressure gradient between the arterial and venous system allows the blood to circulate throughout the body. D) The measurement of the venous BP in the right atrium is known as the central venous pressure.	B) Venous BP is much higher than arterial BP.
Which structure supplies the myocardium with oxygenated blood?	Coronary arteries.
Of the following, which is not one of the three major branches of the aortic arch?	Right subclavian artery.
The aorta bifurcates at the level of the fourth lumbar vertebra into the_________.	right and left common iliac arteries.
Which arteries supply the pelvis and perineum with blood?	internal iliac.
Which arteries supply the neck and head outside of the skull with blood?	External carotid.
Which veins receive blood from the brain, meninges, and deeper regions of the face and neck?	Internal jugular
Which is the longest vein in he body?	greater saphenous.
The anterior and posterior tibial veins unite to form the________.	popliteal vein.
Which of the following statements regarding arterial embolisms is incorrect? A) Emboli can be in the form of air, blood, fat, or tumor. B) Emboli can lodge at bifurcations and vessel narrowing. C) The formation of emboli always causes immediate death. D) Some emboli can be treated with specialized enzymes or high doses of heparin.	C) The formation of emboli always causes immediate death.
Which of the following statements concerning abdominal aneurysms is correct? A) Most abdominal aneurysms arise below the level of the renal arteries. B) Most commonly, abdominal aneurysms rupture directly into the peritoneal space. C) Aneurysms only occur in the larger vessels. D) Ultrasound can be used to detect involvement of the renal arteries, stenosis, and additional aneurysms.	A) Most abdominal aneurysms arise below the level of the renal arteries.
Choose the correct statement regarding an endarterectomy. A) Extensive endarterectomy below the hypogastric level is normally a successful procedure. B) Endarterectomy is performed to alleviate occlusion of an artery. C) Bypass grafting is more advantageous than an endarterectomy. D) The external carotid artery is the most common site for an endarterectomy.	B) Endarterectomy is performed to alleviate occlusion of an artery.
Which graft requires preclotting by the surgical team? A) porous Dacron grafts B) knotted velour Dacron grafts C) PTFE grafts D) woven polyester Dacron grafts	A) porous Dacron grafts
For an aortofemoral bypass, which statement is incorrect? A) The patient will be prepped from midchest to midthigh and as far as possible on each side. B) The STCR should ensure that blood is available for the patient. C) The arterial incision is made with a #10 blade on a long # 3 handle. D) 2-0 OR 3-0 silk ties can be used to ligate larger, deeper vessels.	C) The arterial incision is made with a #10 blade on a long # 3 handle.
Delicate polypropylene suture can be tagged with a_________.	rubber shod.
Typical suture gauge for a femoral vascular anastomosis is________.	4-0.
Which procedure includes a prep from midabdomen to toes, with the affected leg prepped circumferentially?	femoral-popliteal bypass.
Which of the following statements regarding drugs handled by the STSR is correct? A) Papaverine is used intraoperatively to prevent clotting. B) Thrombin can safely be injected systemically to initiate the clotting cascade. C) Heparin in sodium chloride irrigation can be used for intra-arterial irrigation. D) Avitene can be used for intraoperative arteriograms.	C) Heparin in sodium chloride irrigation can be used for intra-arterial irrigation.
Which choice indicates the correct sequence of events for clamping of the vessels prior to an arteriotomy? A) apply proximal clamp, heparinize patient, apply distal clamp, incise vessel. B) apply distal clamp, heparinize patient, apply proximal clamp, incise vessel. C) heparinize patient, apply distal clamp, apply proximal clamp, incise vessel. D) heparinize patient, apply proximal clamp, apply distal clamp, incise vessel.	D) heparinize patient, apply proximal clamp, apply distal clamp, incise vessel.
Which vessels must be clamped during a carotid endarterectomy?	common carotid artery, external carotid artery, and the internal carotid artery.
With what instrument is an arteriotomy initiated?	#11 blade on a #7 handle
Which graft material cannot be safely used in the popliteal space?	porous Dacron graft.
Which approach would be best for an aortofemoral bypass?	anterior abdominal.
The surgical excision of a dilated portion of the aortic wall with immediate reconstruction using a synthetic graft is known as an__________.	abdominal aortic aneurysm resection.
The purpose of a femoral-popliteal bypass is to___.	restore blood flow to the lower limb.
Which statement is correct regarding the positioning of the patient about to undergo a carotid endarterecomy. A) The pt is placed in a lateral position to provide access to the carotid artery. B) The pt should be placed in a supine position, with no further modifications needed. C) The patient should be placed the prone position. D) The patient should be placed in the supine position, with a roll under the scapulae and the head turned away from the operative side.	D) The patient should be placed in the supine position, with a roll under the scapulae and the head turned away from the operative side.
Which clamp is removed last during a carotid endarterectomy?	internal carotid artery.
Which gauge suture is appropriate for closing a carotid arteriotomy?	5-0
Which suture type is appropriate for closing an arteriotomy?	polypropylene.
Which type of needle is appropriate for closing a vessel?	taper.
Which statement is correct regarding the suture for peripheral vascular surgery? A) Single-armed sutures are used for anastomoses. B) Before tying polypropylene sutures, the surgeon's hands should be wet. C) Control release needles are used for vessel anastomosis. D) Patch sutures are typically double-armed sutures.	B) Before tying polypropylene sutures, the surgeon's hands should be wet.
Which statement is incorrect regarding supplies required for peripheral vascular procedures? A) A Doppler probe can be used to dilate vessels. B) A cell saver should be available to reclaim any intraoperative blood loss. C) A butterfly needle, extension tubing, and syringe with radiopaque media should be available to perform intraoperative angiograms. D) A heparin needle and 20 cc syringe filled with heparinized saline is used for intra-arterial irrigation.	A) A Doppler probe can be used to dilate vessels.
Which of the following statements regarding the special needs of peripheral vascular patients is incorrect? A) Peripheral vascular sx patients must be positioned carefully to ensure there is no circulation compromise. B) Peripheral vascular surgery patients must have blood products available intraoperatively. C) Monitors such as arterial lines and Swan-Ganz catheters are not necessary for these patients. D) The patients extremities should be checked for signs of ischemia.	C) Monitors such as arterial lines and Swan-Ganz catheters are not necessary for these patients.
Which artery supplies the upper portion of the digestive tube, the spleen, and the liver?	Celiac.
The suprarenal arteries feed the________.	adrenals.
A fogarty balloon catheter is used for________.	arterial embolectomy.
Which medication is always added to injectable saline for intra-arterial irrigation?	Heparin.
After exposure of the femoral artery, the surgeon will want to_______the artery and will ask for a _________.	isolate, right angle.
An iliac artery obstruction can be bypassed with an________.	femoral-femoral bypass.