Thorax

Published on 10/04/2015 by admin

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Last modified 22/04/2025

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CHAPTER 9 Thorax

Heart and great vessels

Principles of cardiac surgery

Surgery

Most open-heart surgery is carried out via a median sternotomy incision. Closed mitral valvotomy used to be carried out via a left thoracotomy – the operation is rarely performed nowadays. A left posterolateral thoracotomy is used for ligation of a patent ductus arteriosus.

Postoperative complications

Congenital heart disease

The following lesions are most commonly encountered (in order of decreasing frequency): VSD, ASD, PDA, pulmonary stenosis, aortic stenosis, tetralogy of Fallot, coarctation of the aorta and transposition of the great vessels. Congenital heart disease may be classified as cyanotic (significant R-to-L shunt) or acyanotic (L-to-R or no shunt). The reader is referred to a textbook of medicine for the symptoms, signs and investigations of these conditions. The treatment and prognosis are indicated below.

Acyanotic

Acquired valvular heart disease

Ischaemic heart disease

Pericarditis

Complications of pericarditis

Thoracic aorta

Aortic dissection

In aortic dissection, blood breaks through the intima and creates a false passage through the media. This may rupture back into the main lumen leaving an aorta with a double lumen and the patient may survive. In other cases, rupture with exsanguination may occur, or occlusion of the normal lumen may occur with obstruction to the blood flow through the major branches. As dissection advances, occlusion of side branches may occur, e.g. carotid (hemiplegia), spinal branches (paraplegia), renal arteries (anuria and renal failure), visceral arteries (ischaemic bowel). The aneurysm may rupture back into the pericardium with cardiac tamponade and death. Aetiological factors include arteriosclerosis, hypertension, Marfan’s syndrome and cystic medial necrosis.

Thoracic trauma

Management of specific complications of thoracic trauma

Pneumothorax (Fig. 9.1)

Pulmonary infections

Lung tumours

Bronchial carcinoma

This is the commonest cancer in males in the UK accounting for approximately 50 000 deaths per year. It is the second commonest in females. Of all lung cancers, 75% are related to smoking. Other aetiological factors include chronic exposure to asbestos, nickel, arsenic, petroleum products and radioactive materials. Four histological types are described: