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The topics in this book represent the presentations given at the Seventh Annual Meeting entitled "Cardiac Surgery: Current Issues," held at the Frenchman's Reef Beach Resort, St. Thomas, U.S. Virgin Islands, November 9-12, 1994. This symposium was sponsored by the American College of Chest Physicians in conjunction with the Division of Cardiothoracic Surgery of Cooper HospitallUniversity Medical Center, the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden, New Jersey. Chapter authors were charged with the task of writing brief overviews of major issues related to the field of cardiac surgery. The book is specifically tailored to the needs of cardiothoracic surgeons, cardiovascular perfusionists, allied health professionals, and nurs ing personnel involved in all phases of caring for the cardiac surgical patient. Although intended as a reference source with emphasis on updated approaches applied in cardiac surgery, it is hoped that the discussion of these topics will compliment other texts and manuscripts. Obviously, a book of this length cannot cover the whole multidisciplinary and complex field of cardiac surgery. However, co-editors are certain that the annual appearance of this text will highlight comprehensive, new, and interesting approaches to the field of cardiac surgery. The co-editors are greatly thankful to the contributors for their efforts in providing comprehensive chapters. Without their expertise, this work may not have been possible. We would also like to thank Ms. Eileen Birmingham and the staff at Plenum Publishing Corporation for their tremendous help in completing this work.
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.
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 . . . . . . . . . . . . . ."
This book represents the first European effort to provide a collection of test descriptions used in evaluation of the compatibility of biomaterials in contact with tissues and blood. The urge to compile this book arose from the fact that it is the properties of the material which ultimatively seem to determine the functional outcome of a medical device, almost regardless of how ingenious the construction of the very device is. The longer the exposure is, the more important these basic properties become. Unfortunately only a small part of the interactive phenomena is fully elucidated and understood. This challenge reflects itself in an effort to cover numerous aspects of testing, beginning with fundamental analysis of the material, continuing with the mechanical properties, the resistance to degradation and the analysis of surface and chemical properties including adsorption patterns of proteins ending with test on cell cultures, ex vivo and in vivo. A number of the tests which are generally accepted as being important are already described as official requirements (primarily Pharmacopeas). These official requirements are not included in order to limit the size of the book. It is the aim of this book to present the tests like a recipe in a uniform way to ease the reader in finding his/her way through the material and to present it as a kind of "cook-book" in an order to provide an easy access to copy the procedures. This has unfortunately not been possible in all circumstances.
Significant changes have taken place in the realm of cardiac, thoracic, and vascular surgery during the last five to ten years. Many new operative procedures have been developed which remain relatively unknown to cardiothoracic surgeons. This practical manual covers a wide variety of these new processes, several of which are interventions offered to cardiologists practicing in the field of electrophysiology who are unaware that these interventions exist and can help them in situations they cannot solve. It includes general practical techniques; cardiac, thoracic, and vascular surgery procedures; and advances in cardiology and electrophysiology. Throughout the book, illustrations accompany the technical descriptions and show in step-by-step detail how to perform the operations and various procedures using proper equipment. Cardiothoracic Surgical Procedures and Techniques: A Practical Manual is an essential resource for physicians and related professionals, residents, fellows, physician assistants (PA), and graduate students in cardiology, cardiac surgery, thoracic surgery, and vascular surgery.
This heavily revised second edition of this book provides a comprehensive overview of both common and rarely performed thoracic surgical techniques. Techniques covered include thymectomy, left and right lower lobectomy, rib resection for empyema, median sternotomy and lung biopsies. Emphasis is focused on the practical steps necessary to successfully and reliably perform the techniques covered, while acknowledgement is also given to individual variations in how these techniques are performed. Thoracic Surgical Techniques provides a detailed clinical illustrative guide for successfully performing a range of procedures reliably. Its large number of detailed illustrations and concise technical descriptions provides an invaluable resource for all practising and trainee thoracic surgeons.
Attempts to reconstruct various parts of the heart started even before the beginning of open cardiac surgery. By the late 1950s and early 1960 s several closed and open procedures had already been described. In that era, several surgeons in Europe and the Americas were particularly prompted to develop various techniques of valve re construction because of the lack of acceptable valve prostheses and conduits which have become available subsequently. At that time, several congenital lesions still defied definitive correction, and clinical attempts at left ventricular wall replacement had not yet got under way. A renaissance in different cardiac reconstructive procedures started at the beginning of the 1980s. As the problems relating to valve prostheses became more generally appreciated and the importance of chamber volumes and geometry (atrial or ventricular) was accorded due importance in the long-term follow-up, there was a resurgence of surgical attempts at reconstruction in congenital and acquired cardiac lesions so as to approximate the natural state. At the same time several characteristics of this reconstructive "discipline" became apparent. First, cardiac reconstructive surgery has remained a surgical "art" with a gradually increasing number of interested cardiac surgeons."
Fibrin plays a central role in wound healing. It has a hemostatic effect by forming a temporary wound closure and assists in neovascularization and fibroblast prolifera- tion. It therefore makes the repair of injured or severed parts of the human body by simple glueing possible, a notion that men have dreamed of since ancient times. The first modern attempts in this direction, using clotting substances derived from human blood to achieve hemostasis, were reported by Bergel (in 1909), Grey (in 1915), and Harvey (in 1916), who used fibrin powder or fibrin patches to control bleeding from parenchymatous organs. Two decades later Young and Medawar (1940) and Cronkite (1944) used blood plasma or fibrin solutions, adding thrombin to seal nerve anastomoses and to fix skin grafts in humans. Due to the poor adhesive strength of the fibrinogen the results were unsatisfactory. In 1972 a new era in fibrin sealing was initiated by Matras. By using highly concentrated fibrinogen in combination with factor XIII (fibrin-stabilizing factor) and by delaying fibrinolysis with a fibrinolysis inhibitor (aprotinin), a method was developed which after satisfactory results in animals, soon began to be applied in humans.
Die Endoskopie vermochte bisher Gewebsformationen zu dehnen, zu durchtrennen, abzutragen und zu zerstoren. Gewebedefekte auszufullen, miteinander zu vereinigen und zu heilen, war bislang endoskopisch nicht moglich. Die Einfuhrung von Fibrinklebern eroffnete neue Anwendungsbereiche. Der Kleber kann, in seine Komponenten getrennt, uber doppellumige Sonden uber beliebig weite Strecken an den vorgesehenen Einsatzort unter Sicht des Endoskopes transportiert werden. Die Klebung von Fisteln, Rupturen oder Leckagen an Bronchusstumpfen, im Lungenparenchym oder an gastrointestinalen Anastomosen kann heute komplizierte Heilungsverlaufe und riskante operative Re-Interventionen ersetzen. Die spezielle Technik der endoskopischen Fistelklebung wird in diesem Buch erstmals zusammenfassend und interdisziplinar erortert. Daneben werden neue Moglichkeiten zur Stillung gastrointestinaler Blutungen mit Fibrin durch intramurale Injektion oder oberflachlichem Spray besprochen. Grundlegende Untersuchungen zeigen, dass im Vergleich zu anderen Substanzen, die Fibrinapplikation in das Gewebe zu deutlich geringerer Traumatisation und zu geringeren entzundlichen Reaktionen bei gleichem Hamostaseeffekt fuhrt. Ziel des vorliegenden Buches ist, verstreute Einzelbeobachtung zu sammeln, zu ordnen und zu vergleichen, um dem interessierten Leser die neue Technologie der Verklebung von Defekten und der Hamostase mit biologischen Substanzen zu vermitteln.
Effective treatment of acute myocardial infarction remains one of the major issues in cardiology and internal medicine. The present monograph summarizes the relevant experimental data and the results of major clinical trials in the treatment of myocardial infarction. There are contributions of fundamental anatomical and physiological concepts of vascular occlusion and myocardial damage due to ischemia as well as discussions of therapeutic strategies involving thrombolytic agents, adjuvant drug therapy for limitation of myocardial damage, improvement in myocardial tolerance to ischemia and prevention of coronary reocclusion. In this regard, there is an extensive discussion of the role of coronary angioplasty and bypass surgery in the setting of acute myocardial infarction.
Brain injury is one of the most unacceptable complications sustained during heart surgery. This book presents the current results and thinking of a number of leading clinical investigators in this area. Nearly all have been active in serious studies designed to define various aspects of brain physiology, patho physiology, or protection during cardiac operations performed with cardio pulmonary bypass. We were particularly interested in obtaining contributions from younger investigators. Brain injury is a problem which has long troubled those involved with perioperative care of the cardiac surgical patient. The first chapter by Dr. Torkel Aberg presents a summary of his extensive investigations into this problem. It is intended both to present the perspective of a surgeon interested in this problem, and to serve as an introduction to the overall issue of avoiding brain injury during heart surgery. The next three chapters discuss the problem of perfusion pressure, outcome, and brain blood flow. Dr. Sarnquist's contribution stems from his extensive experience with low flow bypass as practiced at Stanford University and the results of the studies he performed in collaboration with Dr. Fish. Drs. Govier and Reves discuss in some detail the general effects of anesthetic agents upon brain metabolic needs as well as their important data demonstrating preserva tion of brain blood flow autoregulation during cardiopulmonary bypass (CPB) as practiced at the University of Alabama. Finally Dr.
Over the past ?fty years, advanced techniques and strategies have arisen in the ?eld of myocardial protection. Meticulous trials, focusing on pulmonary protection during heart surgery requiring cardiopulmonary bypass (CPB), have been missing. This te- book is intended to serve as a useful tool to spread information on strategies for lung protection during heart surgery with CPB. Emphasis on pulmonary protection will be turned to lung perfusion as an adjunct for minimizing the deleterious effects of pulmonary ischemia-reperfusion injury in heart surgery. Many renowned authors have contributed by presenting their expe- ence on lung perfusion in basic research and clinical trials. Furthermore, they have enlightened the quality of this textbook with new ideas, concepts, and future perspectives. The scope of this textbook is of interest to different professionals, such as card- vascular surgeons, pulmonary surgeons, transplantation physicians, cardiothoracic anesthesiologists, intensive care physicians, cardiothoracic fellows, radiologists, basic sciences physicians, cardiologists, pulmonary medicine physicians, perfusi- ists, nurses, students, and researchers. This textbook has 7 sections, aimed at addressing general and speci?c aspects of pulmonary protection during heart surgery with CPB. The ?rst section on general concepts provides information about anatomic, physiologic, histologic, molecular, and radiologic considerations regarding the lungs. The second section focuses on ischemia-reperfusion injury and is composed of several interesting chapters, addressing the basic science aspects of pulmonary p- tection, as well as experimental and clinical experiences from different heart surgery centers worldwide.
This book details all aspects of lung transplantation and equips the general pulmonologist/physician with the necessary tools and knowledge to assist patients with the preparation for and care post lung transplantation. Written by global experts, chapters present general principles and history; indications and eligibility for lung transplantation, including screening for COPD, cystic fibrosis, scleroderma, Idiopathic pulmonary fibrosis (IPF) and idiopathic pulmonary arterial hypertension; approach to and complications of lung transplantation, such as prognostic markers, radiological approach, and immunology and rejection; and medical and surgical guidelines for lung transplantation. The goal of lung transplantation is to increase survival and to provide a greater quality of life for patients with untreatable end-stage lung disease and this book serves to best prepare clinicians in achieving that goal. Lung Transplantation: Evolving knowledge and New horizons offers valuable insights into this modality and is an authoritative resource for multidisciplinary services that include experts in pulmonary diseases, critical care, cardiology, thoracic surgery, infection diseases, internal medicine, radiology , immunology, nephrology, rehabilitation, psychology /psychiatry, nurses, social workers and nutritionists.
In recent years, major social forces such as: ageing populations, social trends, migration patterns, and the globalization of economies, have reshaped social welfare policies and practices across the globe. Multinational corporations, NGOs, and other international organizations have begun to influence social policy at a national and local level. Among the many ramifications of these changes is that globalizing influences may hinder the ability of individual nation-states to effect policies that are beneficial to them on a local level. With contributions from thirteen countries worldwide, this collected work represents the first major comparative analysis on the effect of globalization on the international welfare state.
The Welfare State in Post-Industrial Society is divided into two major sections: the first draws from a number of leading social welfare researchers from diverse countries who point to the nation-state as case studies; highlighting how it goes about establishing and revising social welfare provisions. The second portion of the volume then moves to a more global perspective in its analysis and questioning of the impact of globalisation on citizenship, ageing and marketization.
With its integrative analyses of policy and practice in countries struggling to provide social welfare support for their needy populations, The Welfare State in Post-Industrial Society will become an important voice in the debate on social welfare.
The joint workshop between the European Society of Cardiology and the European Society ofCardiovascular Surgery, held October 14-15, 1983 in Innsbruck, Austria, was a unique event. The idea originated in Atlanta, 1982, with C. Hahn and was supported by V. Bjork and N. Browse. H. Denolin and F. Loogen brought added impact from the European Society of Cardiology. The joint workshop specifically emphasized new trends and controversies in coronary artery surgery. The contri- butions appearing in this edition were selected by a scientific committee: H. Deno- lin, H. Kraft-Kinz, F. Unger, F. Loop, L. Cohn, F. Loogen, P. Lichtlen, T. Killip, and F.Kaindl. The specific aim was to evaluate controversial review points in coronary artery surgery. These were covered in six discussions and in nine forums with slide presen- tations. The topics were: 1. Indications for coronary artery surgery 2. Graft patency and long-term results 3. New operative techniques 4. Myocardial preservation and anesthetic management 5. Combined procedures 6. Long-term follow-up Coronary artery surgery is a model for comprehensive cardiology, whereby sur- gery serves as a link between diagnosis and rehabilitation. Because coronary artery surgery has become a routine procedure with standardized techniques, the demand is increasing dramatically as reflected by enormous waiting lists. Hospital mortality can be kept under 1 %, so that the value of this operation can also be discussed with regard to its social and economic aspects. In the majority of cases, patients improve and finally retum to work, finding life most enjoyable again.
Since the last meeting "Myocardial Biopsy - Diagnostic Signifi cance" was held under the auspices of the International Society and Federation of Cardiology (ISFC) in Munich, many new data and new aspects have been developed in the field of myocardial dis eases. Most importantly, the classification of cardiomyopathies and specific heart muscle diseases, as described in the report of the WHO-ISFC task force (see reference 1 in the Introduction), is now widely accepted as a basis for clinical practice and scientific work. Investigators from all over the world have again assembled un der the auspices of the ISFC at an international workshop on viral heart disease and its implications with regard to congestive cardio myopathy, which was held in Munich January 1983. This book con tains the significant results of the workshop. For practical use, the authors have incorporated important points made in the discussions into their contributions and a subject index has been provided. First of all I should like to thank Professor Riecker, Director of the Medizinische Klinik, Klinikum Grol3hadern, University of Mu nich, West Germany. Without his friendly support in many aspects, this meeting would not have been possible. I should like to thank Professor Goodwin and Dr. Olsen from the ISFC for their active participation and advice in organizing the meeting. Last but not least, I am particularely grateful to all the contributors, whose co operation has made this book possible."
Mankind in the second half of the twentieth century has encountered a number of social and economic problems, which, as never before, determine its future. Among the main problems facing medicine, meriting distinction is organization of the struggle against the increase of cardiovascular and oncological diseases which, with the birthrate, are the main demographic indices of our planet. According to the World Health-Organization, the deathrate from diseases of the cardiovascular system has risen by 60% in recent years, and there has been a sharp increase of myocardial infarctions and cases of sudden death in young people aged 25-30. The "geography" of heart and blood vessel diseases has changed: a dramatic increase of morbidity has been recorded in rural regions, and in districts where 10-20 years ago the native population was practically unaffected by atherosclerosis. Diseases of the cardiovascular system have become widespread among women as well as men. Cardiovascular diseases tax the national economy: they are responsible for over half the mortality among people at the prime of their productive life. More than 50% of temporary disability is also accounted for by ischemic heart disease, hypertension, stroke, etc.
Microcirculation is a rather new field which has been of predominant interest to basic scientists, linking togeth~r technical, hemodynamic, and biochemical aspects. The fmdings elaborated, however, are not only of theoretical interest, but bear in addition great clinical implications. In clinical cardiology this became quite evident by the use of tracers in order to study myocardial perfuSion and by the deSCription of certain clinical entities - such as angina with normal coro nary arteries - which are best explained by "disturbed microcirculation". With respect to this new developing theoretical and clinical field of cardiac microcirculation it was the aim of the Microcirculation Working Group of the European Society of Cardiology to have a symposium on which all different but clinically relevant aspects of cardiac microcirculation will be covered. This symposium, held in Heidelberg in January 1980, was planned not only for the exchange of concepts and ideas, but was expected to be in addition partially a teaching session; the basic scientists should be directed toward a better under standing of the clinical problems, and the clinicians should learn more about the basic mechanisms regulating substrate and ion exchange in such an impor tant organ as the heart, and furthermore the theoretical limitations of some of the diagnostic and therapeutical procedures should be taught. Without a lot of help we would never have succeeded in organizing the sym posium and editing its results.
The International Congresses of Angiology have had a 25-year tradition. Let us remember the 10 previous International Congresses, the first of which took place in Paris in 1952. On this occasion a stimulus for the foundation of the International Union, "Union Internationale d Angeiologie" came into existence. The period of 25 years is lon.qenough to evaluate the scientific progress which has been made in diagnosis, therapy and prevention of vascular diseases. Proceedings of the previous International Congresses of Angiology became attractive resources for scientific information in libraries all over the world. They represent really historic documents of remarkable development of angiology and wittness successful international cooperation in the settlement of serious medical problems of the twentieth century. The Proceedings of the XI. International Congress of Angiology held in Prague 1978 under the stimulating title "Adaptability of Vascular Wall" contains 284 original papers dealing with scientific and clinical research in arterial, venous and lymphatic circulation. The papers are incorporated into 12 chapters according to the main topics. In the first sections the questions of atherogenesis and thrombogenesis are discussed with regard to the adaptability of vascular wall in various metabolic, immunobiologic, and hemodynamic disorders. In the further sections attention is paid to new procedures in investigation, treatment, and prevention of arterial, venous, and lymphatic diseases. Peri pheral microangiopathies, renovascular hypertension, and coronary circulation represent another part."
The first cardiovascular operation in Duesseldorf, a ligation of an open ductus arteriosus (Botallo), was performed in 1938 by E. K. Frey. During the Second World War and the subsequent years many difficulties hindered cardiovascular surgery in Duesseldorf. However, it was resumed on 3 May 1949 by Prof. Ernst Derra, again by ligating an open ductus arteriosus. This was the starting pOint of the successful cooperation between the cardiological and surgical working groups - the "birthday" of the Duesseldorf Heart Centre. Further highlights in cardiac surgery were the introduction of open heart surgery by means of surface-cool- ing hypothermia (9 February 1955) and extracorporeal circulation (21 February 1959) . In addition to cardiac catheterization and surgery in patients with acquired and congenital heart disease, the diagnosis and treatment of arrhythmias was one of the focal points of the centre. On 3 October 1961 the first pacemaker was implanted in a patient with a third-degree AV-block after he had been treated using an external device for about 1 year. In recent years interest has increasingly turned to the tachy- arrhythmias. Close cooperation between the medical and surgical teams made possible the application of new pacing techniques for the treat- ment of tachycardia. In patients with intractable arrhythmias, surgical interventions were made to eliminate the "focus" of the arrhythmia. In the past 2 years intraoperative electrophysiologic studies (endo-cardi- al and epicardial mapping) were applied to enhance the success of the surgical procedures.
Summary A comprehensive review is given of the literature, and the advantages and disadvantages of the bypass operation are discussed in detail. Of all surgical interventions aiming at revascularisation of the myocardium the aorto coronary bypass operation is the one which indoubtedly has earned its place in cardiac surgery. The most suitable candidates for this operation are those with a normal left ventricular angiogram and a good peripheral vascular pattern. Even in these people the question still remains whether the vein can stay patent for many years; moreover what happens to the proximal coronary arteries is as yet uncertain. In the case of poorly contracting ventricles little good is to be expected from the by pass operation. Possible, anastomosis of the internal mammary artery with a stenotic coronary artery merits preference over a venous bypass. To demonstrate the ultimate influence of this type of surgical intervention on life expectance and on a secondary pre vention of angina pectoris and myocardial infarction, Chalmers (1972) and Spodick (1971) favour follow-up studies of patients who are divided at random into a surgical and a non-surgical group. 1.1. OBJECT The object of this investigation is to establish on basis of the results and complications of saphenous vein bypass grafting (briefly termed bypass surgery): - reliable indications for this operation; - to provide the surgeon with a guide to the choice of surgical technique.
The second edition of Front Line Surgery expands upon the success of the first edition, providing updated discussion of practical management of commonly encountered combat injuries.This edition reflects the cutting edge of combat casualty care, refined principles of surgical management of specific injury patterns, and incorporation of the spectrum of recent research advancements in trauma care. Each chapter continues to follow the same organization as the first edition. The "BLUF", or bottom line up front, headlines each topic, providing the critical pearls for the reader, followed by a focused and straight forward discussion of management, pitfalls, and recommendations. In addition, select chapters conclude with a section discussing the application of this topic in civilian practice, as potentially encountered by the rural or humanitarian relief surgeon. Additional new topics include: REBOA and endovascular techniques for hemorrhage control, updates in transfusion and resuscitation practice, active shooter situations, rural trauma management in developed nations, advancements in prehospital care and the Tactical Combat Casualty Care (TC3) course, and discussion of the newest generations of topical hemostatic agents and tourniquets. These additions serve to both enhance the breadth and depth of the material relevant to military surgeons, but should also further expand the applicability and interest in this work to all civilian trauma surgeons.
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