Case Study 9-1: PTCA and Echocardiogram
A.L., a 68-year-old woman, was admitted to the CCU with chest pain, dyspnea, diaphoresis, syncope, and nausea. She had taken three sublingual doses of nitroglycerine tablets within a 10-minute time span without relief before dialing 911. A previous stress test and thallium uptake scan suggested cardiac disease.
Her family history was significant for cardiovascular disease. Her father died at the age of 62 of an acute myocardial infarction. Her mother had bilateral carotid endarterectomies and a femoral-popliteal bypass procedure and died at the age of 72 of congestive heart failure. A.L.'s older sister died from a ruptured aortic aneurysm at the age of 65. Her ECG on admission presented tachycardia with a rate of 126 bpm with inverted T waves. A murmur was heard at S1. Her skin color was dusky to cyanotic on her lips and fingertips. Her admitting diagnosis was possible coronary artery disease, acute myocardial infarction, and valvular disease.
Cardiac catheterization with balloon angioplasty (PTCA) was performed the next day. Significant stenosis of the left anterior descending coronary artery was shown and was treated with angioplasty and stent placement. Left ventricular function was normal.
Echocardiogram, 2 days later, showed normal-sized left and enlarged right ventricular cavities. The mitral valve had normal amplitude of motion. The anterior and posterior leaflets moved in opposite directions during diastole. There was a late systolic prolapse of the mitral leaflet at rest. The left atrium was enlarged. The impression of the study was mitral prolapse with regurgitation. Surgery was recommended.
Case Study 9-2: Mitral Valve Replacement Operative Report
A.L. was transferred to the operating room, placed in a supine position, and given general endotracheal anesthesia. Her pericardium was entered longitudinally through a median sternotomy. The surgeon found that her heart was enlarged with a dilated right ventricle. The left atrium was dilated. Preopera-tive transesophageal echocardiogram revealed severe mitral regurgitation with severe posterior and anterior prolapse. Extracorporeal circulation was established. The aorta was cross-clamped, and cardio-plegic solution (to stop the heartbeat) was given into the aortic root intermittently for myocardial protection.
The left atrium was entered via the interatrial groove on the right, exposing the mitral valve. The middle scallop of the posterior leaflet was resected. The remaining leaflets were removed to the areas of the commissures and preserved for the sliding plasty. The elongated chordae were shortened. The surgeon slid the posterior leaflet across the midline and sutured it in place. A no. 30 annuloplasty ring was sutured in place with interrupted no. 2-0 Dacron suture. The valve was tested by inflating the ventricle with NSS and proved to be competent. The left atrium was closed with continuous no. 4-0 Pro-lene suture. Air was removed from the heart. The cross-clamp was removed. Cardiac action resumed with normal sinus rhythm. After a period of cardiac recovery and attainment of normothermia, cardio-pulmonary bypass was discontinued.
Protamine was given to counteract the heparin. Pacer wires were placed in the right atrium and ventricle. Silicone catheters were placed in the pleural and substernal spaces. The sternum and soft tissue wound was closed. A.L. recovered from her surgery and was discharged 6 days later.
Case Studies, continued
CASE STUDY QUESTIONS
Write the word or phrase from the case study that has the same meaning as each of the following words or phrases:
1. The state of profuse perspiration _
2. Under the tongue _
3. Test of cardiac function during physical exertion _
4. Disease that includes both heart and blood vessel pathology _
5. Excision of the inner lining along with atherosclerotic plaque from an artery (plural) _
6. An abnormal heart sound _
7. Bluish discoloration of the skin; sign of anoxia _
8. The noun form of stenotic _
9. Between the atria _
10. Below the sternum _
Multiple choice: Select the best answer and write the letter of your choice to the left of each number.
_ 11. The word transluminal means:
a. across a wall b. between branches c. through an outer layer d. through a central opening e. across a valve
_ 12. The term that means backflow, as of blood, is:
a. infarction b. regurgitation c. amplitude d. prolapse e. tourniquet
_ 13. The term for a narrowing of the bicuspid valve is:
a. atrial prolapse b. pulmonic stenosis c. mitral stenosis d. mitral prolapse e. atrial stenosis
_ 14. Blowout of a dilated segment of the main artery is:
a. left anterior diastole b. peritoneal infarction
Case Studies, continued c. coarctation of the aorta d. cardiac tamponade e. ruptured aortic aneurysm
_ 15. Sternotomy is:
a. incision into the sternum b. removal of the sternum c. narrowing of the sternum d. plastic repair of the sternum e. surgical fixation of the sternum
_ 16. Extracorporeal circulation occurs:
a. within the brain b. within the pericardium c. within the body d. in the legs e. outside the body
_ 17. Protamine was given to counteract the action of the heparin. This drug action is described as:
a. antagonistic b. synergy c. potentiating d. similation e. addiction
Abbreviations. Define the following abbreviations:
Chapter 9 Crossword Circulation
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