Major epidemiologists from the UK, USA and Europe contribute to the first ever, much needed comprehensive review of the epidemiology of peripheral vascular disease in the lower limbs.

If a consecutive series of patients with lung cancer is followed up until the decision is made about therapy, it emerges that the role of surgery is quite small. Only a very limited proportion will ultimate ly qualify for rationally conceived surgical therapy; most patients are inoperable. In a series of 397 patients investigated at our hospi tal, 78% were inoperable on the basis of preoperative evaluation and a further 3% proved nonresectable at thoracotomy; therefore, only 19% were suitable for resection. On the other hand, surgery is still thought to offer the best, if not the only realistic chance of cure. The question "operable or not?" is therefore of vital importance for the individual patient. The answer to this crucial question must be based on valid guidelines for pa tient selection and preoperative evaluation, and it should be clearly defined what extent of resection is necessary in order to realize any curative intention. In 1972 a thorough analysis of the literature revealed that re section of bronchial carcinoma - although 40 years old - was being undertaken with very variable indications. There was hardly any systematic staging, and assessment of results was hampered by the fact that most communications in the literature were based on retrospective analysis.

La pathologie vasculaire a ete tres marquee par les progres biologiques de ces vingt demieres annees. Le systeme arteriel est main tenant considere comme un organe a part entiere. Modelee au cours de l'organogenese par les facteurs hemodynamiques, Ie paroi arterielle maintient une structure hautement organisee et des proprietes mecaniques qui dependent directement des conditions de pression et de debit. La monocouche endotheliale developpe 2 une surface de plusieurs centaines de m a l'interface sang-tissu; elle est a la fois un organe endocrine complexe synthetisant de nombreuses proteines qui participent a l'hemostase, une surface thromboresistante et hemocompatible, une barriere de permeabilite contr6lant les echanges sang-tissus. Les cellules musculaires lisses constituent un tissu multifonctionnel, contractile, assurant la synthese des composants structuraux responsables des proprietes mecaniques de la paroi arterielle, la transmission de la force contractile, et une etonnante activite reparatrice en reponse aux agressions. Tout ceci est soumis a un ensemble complexe de communications cellulaires qui font de l'endothelium un veritable systeme recepteur pour la paroi vasculaire. Parallelement, ou a la suite de ces progres, l'angeiologie s'est progressivement affirmee comme une specialite clinique. Debordant Ie cadre de la chirurgie vasculaire, elle integre les concepts physiopathologiques au diagnostic et au traitement des maladies arterielles. De cet effort d'integration est ne cet ouvrage, cherchant a concilier les connaissances fondamentales es plus recentes et la demarche clinique.

Expanded knowledge about the pathophysiologic effects of severe in juries, advancements in the intensive care of victims of multiple injuries, and the treatment made possible by modem cardiovascular surgery make it appear sensible to combine the assessment and therapy of thoracic injuries into a synthesis of various branches of medicine. This monograph, therefore, is intended not only for the specialist in thoracic or cardiac surgery but also primarily for the person who is the first to be confronted by thoracic injuries, namely, the general surgeon or the traumatologist. It reflects my own personal experience as chief surgeon of an emer gency surgery ward of a university hospital and as head of an inten sive care unit for the severely wounded, which treats well over 100 patients with severe thoracic injuries annually, and is based on an analysis of these cases. My experience as a military surgeon in Vietnam was also taken into consideration. Many wounds in the area of the thorax can be successfully treated with simple, conservative procedures, though by "conservative" I do not mean to imply "inactive." An aggressive conservatism is need ed, which must pay attention to small details. In given cases, how ever, it requires the quick decision-making capability of the com petent surgeon. For this reason, considerable space is devoted to questions of evaluation and practical procedures."

The spinal cord has a characteristic structure and functions that are distinct from those of the brain. Its functions are tremendously important since it modulates the peripheral sensory inputs to the dorsal horn, and it gives rise to the ascending pathways transmitting peripheral afferent inputs to the brain, and conveys the descending pathways from the brain both to the lower motor neurons, the final common pathway, and to dorsal horn sensory neurons. In spite of these vital functions, the spinal cord constitutes only a small percent age of the mass of the human central nervous system and is located far from the skin surface, which has obstructed the recording of its electrical activity. Recently, however, important advances have been made in several recording techniques, including epidural recording or averaging methods, allowing both sensory and motor evoked spinal cord potentials in man to be recorded. This volume is based on the papers presented at the Fourth International Symposium on Spinal Cord Monitoring and Electrodiagnosis. Each of these international symposia has brought together many of the specialists involved in this research, with an important increase in the number of participants since the first symposium was held in Toyko in 1981. At the past symposia several attempts were made to standardize data, techniques, and clinical applications and to integrate the new findings into patient care."

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.

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."

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.

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 . . . . . . . . . . . . . ."

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."

Since the first pacemaker implantation in October 1958 by Senning and Elmqvist in Sweden, cardiac pacing for bradycardia has become a well-established therapy. The impressive growth of clinical experience and the rapid development of pacemaker devices have greatly contributed to this situation. The electrical therapy appears to be so easy that insertion of the lead and its connection to the pacemaker generator requires little effort, skill or insight. However, after implantation a patient's condition seldom remains stable, which requires a flexible pacing program to cover all new cardiac events, and broad insight from clinician and technical colleagues. The Pacemaker Clinic of the 90's teaches anatomical and electrophysiological aspects of pacing, supports the prevention of complications, and points to new developments in the field. Apart from classical indications for cardiac pacing, the book discusses the validity of the latest indications, supporting the cardiologist and the associated professional in selecting the appropriate pacing mode and pacemaker follow-up in individual patients. The Pacemaker Clinic of the 90's will be a helpful companion for years to come.

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.

In the last decade tremendous progress has been made in the diagnosis and treatment of tumours of the mediastinum. The use of immunohistochemistry, molecular biology, electron microscopy, CT and MRI, and a better knowledge of tumour markers, has made for better diagnosis, often without the need for biopsy, in many cases. This in turn has clarified the classification and thus the epidemiology of tumours of the mediastinum, and modern radiotherapy, chemotherapy and surgery has led to improved survival of patients at risk. With over 300 illustrations, mostly in full colour, and a well-referenced text, this atlas is an invaluable bench reference for the practising diagnostic pathologist and a study aid for the trainee, as well as a comprehensive source of reference for oncologists and surgeons.

The Surgeon as a Humanist Medicine is the most humane of the sciences and the most scientific of the humanities. Cardiac surgery today provides a most natural confluence for the high technology of medicine and the humanistic values traditional in the practice of medicine. The cardiac surgeon must, of necessity, be knowledgeable in physiology and cardio logy, and must also possess consummate surgical technical skill. The attainment of these skills over long years of training leads many of these surgeons to believe or per ceive this long struggle as an apotheosis of their position in life, rather than as an education in bringing the latest scientific advances to the care of patients. The problem lies not only with the cardiac surgeon; it is also contributed to by the patients' perception of heart surgery, heart disease, and the mystery of the science and physiology involved. The patient with heart disease expecting surgery may, for the first time, be facing the finiteness of his existence. The low risk of cardiac surgery to day not withstanding, the coronary surgery patients, most likely a type A personality, is faced with a perceived threat to his invulnerability, his self-image, his family, his independence, his control of situations, and his very existence."

In this book, the latest results in coronary artery surgery are discussed and the factors decisive for long-term prognosis are elucidated. The indications for re-operation are considered and redefined, and the surgical technique with regard to multiple bypass is described. The aim of the book is to depict clearly long-term prognoses and to determinate the future needs of coronary artery surgery in the next decade. This far-sighted approach also makes the book a valuable reference for the planning and extension of cardiology centers in Europe. 1

Advances in heart surgical treatment have been impressive in the last 15 years. In end-stage heart disease, procedures are now performed routinely which were only experimental one or two decades ago. Heart transplantation has become a well-established procedure. According to the Gen eral Registry of the International Society of Heart and Lung Transplantation. 40,738 heart transplantations had been performed through the end of 1997 with survival rates of 78 % at one year, 65 % at five years, and 42 % at ten years. The progress in this field has been due to intense efforts in understanding and modulating immune responses to the trans planted heart, to elaborate therapeutic strategies to constrain infections, and to improved out-patient care. Accordingly, heart transplantation is integrated into the facilities of the health care systems, the routine of physicians, and the awareness of patients. The resulting increase in potential organ recipients has not been met, however, by an equivalent increase of available donor organs. This increasing discrepancy has forced the technical improvement and clinical evalua tion of mechanical circulatory support systems as an option for treatment of critically ill patients with a failing heart. Initially, these assist devices were only used to maintain sufficient circulation in post-cardiotomy heart failure until myocardial function had recov ered. Since the late 1980s, their primary use has been that of bridging patients with heart failure until a suitable organ is available so that heart transplantation can be performed."

It is a great pleasure to have the opportunity to edit a new volume of "Assisted Circulation." In the past 5 years there have been many changes in the philosophy of assisted circulation. There have been a large number of clinical application- of left ventricular assist devices, biventricular assist devices, and total artificial hearts; one artificial heart was implanted electively in December, 1982, in a patient with an end-stage cardiomyopathy. A great deal of help is necessary in editing a book. I want especially to thank the Austrian Research Council and the University of Innsbruck for their support of my work. I am most grateful to my co-workers R. Schistek, I. Koller, J. Hager, and R. Nessler, and especially to my secretary, W. Kirchner, who had the most secretarial load ofthe editorial work. I would also like to thank Dr. J. Wieczorek, Mrs. M. Schafer, Mrs. M. Griindler, and the Springer staff who gave this second volume an attractive format and made it accurate as usual. It was with great sorrow that we learned of the sad death of Dr. Emery Nyilas in June 1984, who played a great part in the development of artificial hearts. I hope that this second volume will also raise new items for discussion, resulting in new concepts, so that the third volume can introduce new devices and report on more clinical applications.

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."

Nach den femorokruralen und aortoiliakalen VerschluBprozessen fruherer Bande wurde fur diesen Band der Oberschenkel-VerschluBtyp gewahlt. Schon morpholo- gisch weist diese Etage eine Besonderheit auf, denn sie besitzt mit der tiefen Ober- schenkelarterie eine Arterie, die Linton schon 1964 als besten korpereigenen Bypass bezeichnete. Urs Brunner nannte die Profunda gar die Konigin der Beinarterien. Dies beruht auf ihrer besonderen Kollateralisierungsbefahigung. Dem ist es zuzu- schreiben, daB das therapeutische Spektrum auf dieser Etage wesentlich breiter ist als in den beiden anderen VerschluBetagen. Andererseits ist dieser VerschluBtyp am haufigsten mit anderen VerschluBlokalisationen kombiniert, so daB eine ausschlieB- lich auf den Oberschenkel-ArterienverschluB gerichtete Betrachtung nicht moglich und naturlich auch nicht sinnvoll ist. Wie es in dieser Reihe ublich ist, wurde versucht, das Gebiet umfassend darzustel- len. Das erforderte eine umfangreiche interdisziplinare Bearbeitung, wozu auch namhafte Experten aller Bereiche gewonnen werden konnten. Diagnostik, physik ali- sche Therapie, konservative Behandlung, operative Verfahren und kombinierte MaBnahmen konnten so in einem Band zusammengefaBt werden. Zu betonen ist, daB die dargestellten Behandlungsverfahren nicht als konkurrierende Therapieprin- zipien sondern als sich sinnvoll erganzendes therapeutisches Spektrum in Abhangig- keit yom Stadium der DurchblutungsstOrung anzusehen und einzusetzen sind. Den Referenten ist es zu danken, daB dieser Band trotz vieler Schwierigkeiten doch noch relativ zeitgerecht erscheinen wird. Auch Frau Sabine Muller und ihrem Team yom Dr. D. Steinkopff-Verlag, mit der mich nun schon eine mehrjahrige ver- trauensvolle Kooperation verbindet, mochte ich fur ihre wertvollen Anregungen und ihre Unterstutzung danken.

Concise, recent data are presented on obstetric problems arising in patients with cardiovascular diseases (not only congenital and acquired valvular heart diseases and hypertension, but also uncommon heart lesions) and on cardiological complications encountered in pregnant women. The goal of the book is to provide obstetricians with necessary cardiological information and cardiologists with essential obstetric information to enable both specialists to make optimal decisions regarding the permissibility of pregnancy, management of pregnancy and labour, or termination of pregnancy, and selection of an adequate form of contraception in women with heart and vascular diseases. Along with recent scientific findings, the book contains practical recommendations for examination diagnosis and treatment that is effective for the mother and safe for the fetus.

D. B. LONGMORE The concept ofthe meeting on which this book is based is unique. There has never be fore been a multi-disciplinary meeting based entirely on the concept of making a major branch of surgery safer. Hopefully, this meeting will be archetypal and will set a precedent for similar attempts in other disciplines as well as future efforts to make cardiac surgery safer. Cardiac surgery is still a rapidly growing discipline even after a quarter of a century of experience. Like any new area of science, or medicine, initially there is an exponential growth ofwork, publications, meetings, options of available equipment and all the ancillary and peripheral disciplines associated with it. The ideas of the handful of original surgical pioneers, some of whom have contributed to this book, formed the basis of a still rapidly growing young branch of surgery with a whole new medical discipline of total extracorporeal circulation involving biochemical and haemodynamic control of a patient.