Circulation through the deep femoral artery and its branches is critical to patients with aortoiliac and infrainguinal arteriosclerosis. It is, accordingly, essential that all physicians who are seriously interested in treating patients with lower extremity ischemia have a good working knowledge of this crucial artery's anatomy and func tion. It is equally essential that they be aware of arteriosclerotic disease patterns that involve this important artery, how these patterns can be Clccurately defined, and, most importantly, what therapeutic options are available and when they should be used. All this important information relating to the deep femoral artery and its surgical significance is included in Dr. Merlini's fine volume. Eighteen authors have contributed 11 well-edited and nicely illustrated chapters that provide all the facts that the com mitted vascular surgeon would ever want to know about the deep femoral artery and how it should be managed in patients with lower limb ischemia. Although some of the chapters overlap in some areas, this adds to the value of the book since the different authors are' all acknowledged experts and their varying perspectives. are beneficial to a reader seeking to formulate his own unbiased views.

The papers presented in this book were held at the International Sym posium on "Prognosis of Coronary Heart Disease - Progression of Cor onary Arteriosclerosis" on October 22 and 23, 1982 in Bad Krozingen, FRG on the occasion of the 10th anniversary of the Rehabilitationszen trum Bad Krozingen. The symposium was sponsored and supported by the European So ciety of Cardiology and the Pharma Schwarz Co. The scientific com mittee was composed of F. Loogen (Dusseldorf), P. G. Hugenholtz (Rotterdam), and the editor of this book. To all of these and to my co-workers many thanks. Bad Krozingen, August 1983 H. Roskamm Table of Contents W. Steinbrunn and P. R. Lichtlen Prognosis of Patients with Coronary Heart Disease Evaluated Using Data Obtained by Invasive Methods . . . . . . . . . . . . . . . . . . . . . . . . 1 R. A. Bruce Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Noninvasive Methods . . . . . . . . . . . . . . . . . . 16 K. Bachmann, W. Niederer, H. Fuchs, and H. Holzberger Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Invasive and Noninvasive Methods . . . . . . . . . . . . . . 24 R. Balcon, M. Cattell, and K. Wong Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Angiography and Exercise Testing . . . . . . . . . . . 36 M. Kaltenbach and W. -D. Bussmann Prognostic Relevance of Findings from Invasive and Noninvasive Investigations in Coronary Heart Disease Patients . . . . . . . . . . . . . 44 H. Gohlke, L. Samek, P. Betz, and H. Roskamm Prognostic Relevance of Invasive and Noninvasive Data in Angiographically Defined Subgroups of Coronary Heart Disease Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 v. F."

Our common interest in surgery of the vertebral artery was born in 1976, when as residents in the same hospital, we attended an attempt by two senior surgeons to treat an aneurysm of the vertebral artery at the C 3 level. Long discussions had preceded this unsuccessful trial, to decide if surgery was indicated and to choose the surgical route. Finally a direct lateral approach was performed, but access was difficult and correct treatment was impossible, resulting in only partial reduction of the aneurysmal pouch. Following this experience, we decided to seek a regular and well defined approach for exposition of the vertebral artery. Review of the literature indicated some surgical attempts, but the descriptions did not give the impression of safety and reproducibility. No landmark on the described surgical route appeared sufficiently reliable. Henry's anatomical work (1917) gave the only accurate description on vertebral artery anatomy, and it became the basis for our work. When the same patient was referred again one year later, after a new stroke in the vertebro-basilar system, we had behind us repetitive experience on cadavers of an original approach to the distal vertebral artery.

Jean Natali The pathophysiology and management of chronic critical limb -ischaemia (CLI) has always been a problematic area, at least partly because it involves doc tors from a wide range of the traditional medical specialities including vascular surgery, angiology, diabetology, haematology and radiology. The treatment of these patients also varies largely with local circumstances and national traditions. CLI therefore seemed a particularly appropriate subject for a new type of European consensus approach. In 1988 a series of small workshops were held by the European Working Group on Critical Limb Ischaemia to discuss the definition, pathophysiology, in vestigation and management of this condition. The process culminated in a meet ing in Berlin in March, 1989 where 120 specialists from sixteen European countries, representing the basic sciences as well as a spectrum of clinical dis ciplines, met to evolve a Consensus Document on the subject with specific recom mendations. The Document, which is reproduced in the first section of this book, does not of course necessarily represent the unanimous view of all those who participated in its compilation; however it is agreed that it does represent a con sensus or majority view. It was also noted that the comments and recommenda tions in the document should be taken as a whole, and are not intended to dictate the only correct approach to individual treatment.

In patients with coronary artery disease, surgical revascu- larization with arterial or venous bypass grafts not only relieves symptoms, but also prolongs life. The result of such interventions, however, is frequently impaired by graft dysfunction and occlusion. This monograph highlights the clinical importance of coronary artery bypass graft disease and, in particular, the use of modern diagnostic techniques to assess graft structure and function. The molecular and cellular mechanisms of coronary bypass graft disease are ex- tensively discussed with several chapters devoted to prophy- lactic medical therapy. The indication, technique and results of reinterventions with balloon angioplasty, reope- ration or transplantation in patients with graft failure are also reviewed.

Reconstructive microvascular surgery is now in its teens. At first many thought this new child was a whim and would fail to thrive. Some were un certain, others with vision either supported or became actively involved in this new area of surgical endeavour. Although initial interest was focused on the replantation of amputated parts, it has been the one stage free trans fer of living tissue to a distant site which has launched microsurgery into the surgical spotlight. From its humble beginnings we have witnessed a revolution in this branch of plastic surgery; many of the long established methods of recon struction have, like barricades, fallen before the advances made in this field. In its infancy there were relatively few procedures available. There was a tendency to make the patient's problem fit the operation, rather than the reverse, and this frequently led to an inferior result. The then known flaps, such as the groin flap and the deltopectoral flap, were employed. Unfortunately they were sites which posed many technical problems; namely those of vascular anomaly, a short pedicle and vessels of small cal ibre. Long operations were the norm, and vascular thrombosis was not un common. Hospital routine often was disrupted and there was a danger that these new techniques would fall into disrepute. Over the last decade this state of affairs has changed dramatically.

Originally published in 1980-1981 as a two-volume set, the Manual of Cardiac Surgery has been completely revised and now includes new full-color illustrations in a single convenient volume. This new edition maintains the high standards established in the first edition: insightful descriptions of various cardiac surgical procedures illuminated by clear, brilliant illustrations.

After 7 years of clinical use, percutaneous transluminal coronary angio plasty (PTCA) has now found worldwide acceptance, and its basic techniques are well standardized. A growing number of invasive cardi ologists are acquainting themselves with the procedure in order to be in a position to offer new therapeutic options to their patients. However, the transition from the diagnostic to the therapeutic intervention is not always easily accomplished. Certain prerequisites concerning technique, the physician, technical equipment, and program organization are necessary for safe and effective performance. The consequences of unsuccessful coronary angioplasty range from waste of time and money to severe complications for the patient; the decision to perform PTCA needs to be based on sound indications and techniques according to the best current scientific evidence. Techniques and technology for coronary angioplasty continue to evolve. Scientific evidence of its short-and long-term value continues to accumulate, and applications of the procedure are still being extended. This volume is obviously no substitute for well-guided hands-on experience with the procedure; it is intended rather to present current policies of patient selection and patient management; to describe standard techniques (femoral and brachial approaches) and potential applications; to point out problem areas and limitations of the proce dure; and to provide tips that may be useful even for the more experienced angioplasty operator."

This authoritative guide on reconstructive techniques for degenerative mitral valve disease presents step-by-step instructions for each procedure pioneered by Alain Carpentier, MD, PhD. More than 200 detailed anatomic drawings provide clear depictions so that you can effectively apply the techniques of a master. Apply the techniques and procedures of Dr. Alain Carpentier-pioneer of mitral valve reconstruction-to your practice. View more than 200 detailed anatomic drawings that depict reconstruction procedures clearly. Master each procedure using step-by-step instructions and a consistent chapter format. Grasp the nuances of procedures thanks to "tips from the Master" and a section of questions and answers. Tap into the knowledge and experience of leaders in the field of mitral valve repair and reconstruction.

Over the past ten years, cardiac transplantation has evolved from an exper imental procedure performed in a handful of university centers to a viable therapeutic modality now performed in more than 150 centers worldwide. The complexity of the procedure, the changing immunosuppressive re gimes, and the follow-up care have necessitated a multidisciplinary ap proach involving a variety of medical, nursing, and social sciences special ties and subspecialties. In addition, health care trainees and referring physicians are increasingly becoming involved in the care of the cardiac transplant recipient. This book does not attempt to be a comprehensive treatise on cardiac transplantation; rather, we hope that it will serve as a manual and guideline for all health professionals involved in cardiac trans plantation. JEFFREY D. HOSENPUD, M.D. Contents Preface v Contributors IX 1. Cardiac Transplantation: An Overview JEFFREY D. HOSENPUD AND ALBERT STARR Immunogenetics and Immunologic Mechanisms of 2. Rejection 15 DOUGLAS J. NORMAN 3. Medical Therapy Tailored for Advanced Heart Failure 33 LYNNE WARNER STEVENSON 4. Ventricular Assistance as a Bridge to Cardiac Transplantation 53 D. GLENN PENNINGTON AND MARC T. SWARTZ Recipient Selection for Cardiac Transplantation 71 5. GEORGE A. PANTELY 6. Donor Selection and Management for Cardiac Transplantation 85 JEFFREY SWANSON AND ADNAN COBANOGLU 7. Operative Techniques and Early Postoperative Care in Cardiac Transplantation 95 ADNAN COBANOGLU Endomyocardial Biopsy: Techniques and Interpretation of 8."

Surgery of tje Arteries to the Head provides residents and practicing surgeons with detailed descriptions and explanations of various surgical techniques. Written in essay style, it presents an opinionated discourse based on the collective experiences of leading vascular surgeons.

The motivation for this book was the recognition by two of us (RL and TL) that, despite our training as cardiologists, we had a limited understand ing of many aspects of the surgical management of our patients. Conversa tions with other cardiologists at our own institution and at other medical centers around the country convinced us that many of our colleagues shared our uncertainty about the details of surgical procedures and the factors that determine decisions in the perioperative period. As surgical techniques continue to evolve, this knowledge gap can become only more severe. We therefore compiled information about cardiac surgery that might be useful for cardiologists and other nonsurgeons. We asked cardiologists what questions they would like to ask their surgical colleagues and provided these questions to the authors of the chapters. Thus, the goal of these chapters is to help nonsurgeons answer their own questions about common cardiac procedures, and to help prepare these physicians to address the questions raised by their patients. In addition, we hope that insight into these issues will improve communication between surgeons and their col leagues-and, ultimately, lead to better patient care. Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 1 Chapter 1. Anesthesia for Cardiac Surgery JONATHAN B. MARK Chapter 2. Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 DANIEL FITZGERALD Chapter 3. Myocardial Protection in Cardiac Surgery . . . . . . . . . . . . . . . . . . 23 JEFFREY SELL Chapter 4. Coronary Artery Bypass Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 HENDRICK B. BARNER Chapter 5. Surgery for Left Ventricular Outflow Obstruction: Aortic Valve Replacement and Myomectomy . . . . . . . . . . . . . ."

The history of electric cardiac stimulation is long and fascinating. The grow- ing clinical importance has been recognized and renewed as Zoll in 1952 described a successful resusciation in cardiac standstill by external stimula- tion. Meanwhile, patients with disorders of cardiac rhythm have been treated all over the world for about 15 years. Recently the technical refinements of intracardiac stimulation in combination with a subtile analysis of endocavi- tary electrocardiograms improv~d the understanding of human intracardiac conduction. These new procedures include the possibility to study the initia- tion and termination of tachycardias. - The pertinent interest in these devel- opments and the intention to learn more about the basic fundamentals of excitability and conduction under both normal and pathological circum- stances were reasons to organize an international symposium on that topic. - The papers contained in this book were presented at this meeting on diagnos- tic and therapeutical tools of cardiac pacing, held at Munich on November 7 and 8, 1975, sponsored by the first Medical Clinic of the University of Munich and generously supported by Medtronic. Especially focused are the investigations on sinus node function, disturbances of av-conduction and electrophysiology of supraventricular and ventricular tachycardias. The content of the book that is emerging from the symposium were created by the authors. I wish to thank them for teaching us about the recent advances in cardiac tissue stimulation by electricity. Much credit is due Priv. Doz. Dr. B. Uideritz, who organized the symposium and published these proceedings.

"Duplex Sonography" is the first comprehensive text written about this modality. The book offers the reader detailed information about all major uses of duplex and is introduced by a brief chapter on the physical principles of doppler ultrasound as it relates to duplex scanning. "Duplex " "Sonography" is intended to provide relevant information on all aspects of the technique, ranging from the basics of performing the examination to the features of sometimes complex pathological states. The book is intended for anyone interested in non-invasive vascular diagnosis including radiologists, vascular surgeons and ultrasound/peripheral vascular technologists. Other groups may find individual chapters appealing: carotid/cardiac sonography for cardiologists, fetal sonography for obstetricians or carotid sonography for neurologists. Each chapter is not only a guide to duplex evaluation, but also provides valuable information about vascular dynamics of the organ system under discussion. Physicians or technologists reading this book should come away with a well-rounded background in state-of-the-art duplex sonography and will undoubtedly discover new possibilities for using this non-invasive vascular technique.

Here, two of the foremost cardiothoracic surgeons have brought together many of the top cardiologists and haematologists to produce the most current reference source on all aspects of blood conservation, from an overall clinical approach to the use of erythropoietin and the benefits of post-operative blood salvage. The subject matter covers numerous areas involved in the preoperative considerations in cardiac surgery, the intraoperative decision-making in cardiac surgery, postoperative bleeding and management and a section on the algorithm for bloodless surgery used at the New York Hospital-Cornell Medical Center.

Interventional cardiology means the cardiological practice of the future. This book provides the physician with practical guidelines to interventions. All procedures involving modern technology and drugs are described with emphasis on the "how to" aspects. The indications, techniques, results and merits of each procedure are given. These include: coronary angioplasty and angioscopy, valvuloplasty, lasers and cardiac transplantation as well as basic procedures such as cardiac catheterization, electrophysiologic studies and automatic implantable defibrillators. Readers of the book will find the way to new dimensions in cardiologic practice.

This book consists of an edited report of the proceedings of the Fifth Cardiac Surgical Course run by the Royal Post-Graduate Medical School, The Institute of Cardiology, The Institute of Diseases of the Chest, The Institute of Child Health, The National Heart Hospital, The Brompton Hospital, The Hammersmith Hospital and Great Ormond Street Children's Hospital. These organisations encompass most of the major London hospitals associated with cardiac surgery. The course has been run annually, its aim being to help young men and women who are training in the specialised field of cardiac surgery. Thus this book consists of the proceedings of a teaching course rather than of a symposium, the 60 authors having been charged with the task of teaching rather than displaying their results or discussing their latest ideas and the proceedings reflect an interesting appraisal of the current status of cardiac surgery. The speakers were chosen from all over the world, because they were leaders in their field or because they have access to up to date and reliable information, and I am grateful to all the lecturers for their cooperation in the production of this volume. Ten thousand surgical cases are reported. These figures are drawn from experience in the United Kingdom, France, Germany, Switzerland, the United States of America, Australia and New Zealand. The reader may be surprised to find that only a handful of experiments are described.

In November 1986, I was invited to attend a symposium held in Barcelona on Diseases of the Pericardium. The course was directed by Dr. J. Soler-Soler, director of Cardiology at Hospital General Vall d'Hebron in Barcelona. During my brief but delightful visit to this institution, my appreciation of the depth and breadth of study into pericardial diseases, carried out by Dr. Soler and his group, grew into the conviction that these clinical investigators have accumulated a wealth of information concerning pericardial diseases, and that investigators and clinicians practicing in English speaking countries would greatly profit from ready access to the results of the clinical investiga tions into pericardial disease carried out in Barcelona. The proceedings of the Barcelona conference were published in a beauti fully executed volume in the Spanish language edited by Dr. Soler and pro duced by Ediciones Doyma. Because I believe that this work should be brought to the attention of the English speaking scientific and clinical com munities, I encouraged Dr. Soler to have the book translated into English. I knew that this task could be accomplished and that the book would be trans lated into good English without change of its content. My confidence was based upon a translation of my own book, The Pericardium, into Spanish undertaken by Dr. Permanyer, who is a contributor and co-editor of the pre sent volume."

A major need of all cardiologists and surgeons involved with the application of allograft tissue to cardiac surgical reconstructions is met by this unique atlas. Step by step, it carefully describes the procedures involved in acquiring, sterilizing, and cryo-preserving allograft valves as well as the surgical technique used in left and right ventricular outflow tract reconstructions. All of the information needed to perform the reconstructions is given, including relevant references and applicable variations in method. Excellent illustrations accompany the description of surgical technique. All of the techniques are based on classic approaches, but assimilate the authors' modifications arrived at through vast experience. The wealth of references, illustrations and expertise in this volume make it a valuable asset for all cardiac surgeons.

"Prospects of Heart Surgery: Psychological Adjustment to " "Coronary Bypass Grafting" reports on a study of how patients and their spouses adjusted to the prospect, and then to the outcome, of coronary graft surgery. The focus upon patients' social relationships rather than upon individuals reveals that the way people bear their illness, and adapt to symptom removal, is part of a wider adjustment involving both the spouse and other individuals. The book offers, as one of its main contributions, a social-psychological approach to the study of illness in general. It sets out a new methodology which might be applied in a number of illness contexts. Using both qualitative and quantitative analyses, "Prospects " "of Heart Surgery" describes differences between smooth and problematic approaches to surgery as well as variations in the experience of rehabilitation afterwards.

Dr Rose honoured me with a request for a Foreword. I am delighted to oblige. The treatment of valvular heart disease has improved remarkably in the past 40 years. Many factors have contributed; not least being the introduction of artificial heart valves for treatment, more than 25 years ago. Their use has shown that they are good, but not an ideal substitute for native valves. A galaxy of pathological changes are associated with the insertion and malfunction of artificial heart valves. Each has to be defined, classified and related to clinical procedures or problems with a prosthesis; then a means sought to prevent them. Often, in understanding their cause, investigative procedures have/will improve patient care and broaden knowledge in other spheres. Dr Rose has been a student of this pathology for many years and has made many contributions. No doubt his interest in the area was whetted by colleagues in Cape Town, leaders in the field of cardiovascular medicine and surgery. This monograph provides a collected review of his experience. In it one finds lessons in geographic pathology, in considering the causes of valvular heart disease in Cape Town and valuable information regarding the identification of artificial heart valves and a means of examining a heart bearing one.

Based on the research and clinical work presented at the Sixth International Symposium, Vascular Surgery 1992, this book gathers contributors from renowned clinicians and researchers and outstanding young investigators from around the world.

Amaurosis fugax, or "fleeting blindness," has been known as a clinical entity for hundreds of years (1). Since 1859, we also have understood that the phenomenon frequently is related to atheroembolic disease and that it is considered a classic manifestation of ocular transient ischemic attacks and a potential precursor to stroke. However, many questions about this syndrome have remained unanswered until quite recently, when a great deal of new information and thought has been directed to the subject. Transient monocular blindness (TMB) is only one manifestation of a complicated syndrome of ocular, systemic, and cerebral diseases that may include some degree of monocular blindness. The duration of blindness varies from very brief (seconds) to complete and permanent. The per manent type is referred to as ocular infarction or ocular stroke. Retinal infarction is the most severe degree of monocular blindness and usually is due to embolic occlusion of the central retinal artery or one of its branches. Varying types of arterial emboli have been described, including thrombus, cholesterol, platelets, and fibrin.

Among the greatest challenges in cardiovascular surgery today remain operations on aortic arch pathology, supraaortic vessels, and the protection of the brain from hypoxic or ischemic injury during these delicate operations. Since DeBakey's first successful repair of an aortic arch aneurysm in 1957, understanding of the aortic arch pathology, neuroprotective strategies, neuromonitoring and surgical technique have markedly improved. Although the specific surgical procedures have reached an advanced standard and general acceptance, many questions remain unanswered and have contributed to ongoing controversy.
Cerebral Protection in Cerebrovascular and Aortic Surgery presents the current knowledge of understanding causes and pathogenesis of cerebral damage during surgery on the aortic arch and supraaortic vessels and prevention of brain damage by specific surgical therapy.

During the past three decades, Vascular Surgery has emerged as a specialty within general surgery. Fellowships are now available to equip surgeons with specialized skills for managing various vascular problems. Nev ertheless, the vascular surgical emergency, one of the greatest challenges in surgical management, may occur suddenly and at a time and place remote from the highly qualified vascular surgeon or a specialized center where complex vascular treatment is routine. The initial evaluation and treatment must be undertaken by a general surgeon who determines the extent, sever ity, and urgency of the problem at hand, and hopefully will arrange appro priate transfer to a specialized center if the patient's condition permits. Urgent problems, on the other hand, demand immediate surgical interven tion by the general surgeon if any hope for salvage is to occur. It is in this set ting that this volume offered by Professor Staudacher may be of assistance to the general surgeon whose experience in this type of emergency may be limited. This concise, well illustrated volume should serve as a guide to manage the peripheral vascular emergency involving either the arte rial or venous system."