Reviews the best therapies and surgical techniques available to provide quality care for the elderly cardiac patient and of those areas that require further research. The authors detail preventive therapies and the cardiovascular syndromes that disproportionately afflict the older individual, including arrhythmias (particularly atrial fibrillation), syncope, heart failure (particularly diastolic heart failure), and ischemic heart disease. They also delineate the surgical management of the heart patient with discussions of postoperative management and its complications and of specific surgical procedures such as coronary artery bypass grafting, valve surgery, pacemaker and defibibrillators, and surgical management of heart failure.

Our purpose in writing this book was to produce a clinically-oriented, non-multi-au- thored textbook ofcardiac electrophysiology that would be useful to practicing electro- physiologists, cardiologists, fellows in training as well as associated electrophysiology professionals, including nurses and technologists. While all clinical textbooks risk be- coming outdated even before they're published, and few textbooks ofa manageable size can claim to be completely comprehensive, our goal was to produce a book that system- atically presents a thorough discussion ofthe fundamental principles and concepts im- portant to the practice of clinical electrophysiology. We do not discuss basic cellular electrophysiology for its sake alone, but instead include basic science material only when itis helpful in explaining the overlying clinical principles. Cardiac electrophysiology, as with any subspecialty, behaves as a living organism with continuous evolution of its standards and practices. However, even though the details and tools of management (catheters, drugs, devices, etc. ) may change with dazzling speed, the fundamental princi- ples ofdiagnosis and management generally change very little and they remain the criti- cal underpinning ofthe day-to-day management ofpatients with cardiac arrhythmias. In the first third ofthe book we present the principles ofclinical cardiac electrophysiolo- gy as it is currently practiced.

Some 25 years ago, the coronary care unit concentrated high technology and the acutely ill patients who might benefit from it in a single, recognizable space. Since then, that space and its technical equipment have changed, as has part of its population. Acute ischemia, silent and manifest, occurs within and outside of the coronary care unit as pain, arrhythmia, or pump failure. Its detection and treatment require the utilization of many diagnostic techniques and skills, not the least of which is two-dimensional Doppler echocardio graphy, which is gaining importance. Future developments, in tandem with computer technology, may add to this importance by enabling tissue identification, spatial representation, and Doppler flow mapping. This book describes the state of the art for the practicing clinician using Doppler echocardi?graphy at the bedside of patients with acute ischemic manifestations of coronary heart disease. The first requirement is to move from the echo laboratory to the coronary care unit, emergency department, operating room, or catheterization laboratory, using equipment suited for that purpose. The second, more trying imperative is to secure good cooper Ition between those treating the acutely ill patient and the investigator who interferes with his probes. If successful ceeding in both, rewarding results can be obtained, since echocardiography is a very sensitive and specific tool for recognizing and quantifying early ischemia.

Although some investigators have questioned the importance and even the existence of silent myocardial ischemia, documentation presented at this two day symposium leaves little doubt about its existence and importance. It has been estimated that about 3 million of the estimated 4 million angina sufferers in the United states have frequent episodes of silent myocardial ischemia. Although it is not possible to define how many Americans die due to silent ischemia, it has been suggested that the mortality rate may exceed hundreds of thousands of victims annually. Unfortunately, there still remains a lack of definitive information as to why some ischemic events are painless. Some suggest the concept that the location and size of the myocardium at jeopardy relates to pain, that the pain threshold varies from patient to patient or that there are neurological deficits in the myocardium of some patients with silent ischemia. Abnormalities in myocardial perfusion and function can occur without pain. An interesting observation presented by several investigators has been that when a coronary artery is occluded in man, no ischemic pain is perceived for the first 30 seconds. Only after a 30 second period or so of occlusion does angina occur. An even more confusing observation is that some 30 second periods of occlusion of the same vessel in the same patient results in angina while the next occlusion can be a totally silent event.

Nitrates remain among the most commonly used therapeutic agents in cardiology. That they can re lieve pain in angina pectoris has been known at least since 1867, when Lauder Brunton described their clinical use. Now, almost 130 years later, we are constantly learning more about their optimal use in anginal syndromes. For example, there is no doubt that nitrate tolerance occurs, but equally no doubt that certain drug dosages help to attenuate such toler ance. Thus, our understanding of nitrate tolerance has been taken further by the advent of new nitrate preparations and by studies at a basic science level. The current intense interest in nitrates has been rekindled by the growing emphasis on the role of the endothelium in the production of nitric oxide, a basic cardiovascular regulator. If nitric oxide is vasodilator and protects the vascular endothelium, then nitrates should also have similar properties. Hence this book starts off with the role of the endothelium and ni trates in vasodilation. Next, the mechanisms of ac tion of nitrates are considered with emphasis on the role of cyclic GMP. The chief limitation to the use of nitrates lies in nitrate tolerance. After carefully looking at all the evidence, the authors of the third chapter conclude that the mechanism is likely to be multifactorial. The mechanism responsible for the tolerance still remains unknown. In vitro tolerance may be due to enhanced production of vascular superoxide 1]."

How is the heartbeat generated? What controls the strength of contraction of heart muscle? What are the links between cardiac structure and function? How does our understanding of skeletal and smooth muscle and non-muscle cells influence our thinking about force development in the heart? Are there important species differences in how contraction is regulated in the heart? How do the new molecular data fit together in understanding the heart beat? What goes wrong in ischemia, hypertrophy, and heart failure? This book paints a modern portrait' of how the heart works and in this picture the author shows a close-up of the structural, biochemical, and physiological links between excitation and contraction. The author takes the reader through a series of important, interrelated topics with great clarity and continuity and also includes many useful illustrations and tables. The book starts by considering the cellular structures involved in excitation-contraction coupling and then described the characteristics of the myofilaments as the end effector of excitation-contraction coupling. A general scheme of calcium regulation is described and the possible sources and sinks of calcium are discussed in simple, but quantitative terms. The cardiac action potential and its many underlying currents are reviewed. Then the characteristics of some key calcium transport systems (calcium channels, sodium/calcium exchange and SR calcium uptake and release) are discussed in detail. This is then built into a more integrated picture of calcium regulation in succeeding chapters by detailed discussions of excitation-calcium coupling mechanisms (in skeletal, cardiac, and smooth muscle), the interplay betweencalcium regulatory processes, and finally mechanisms of cardiac inotropy, calcium overload, and dysfunction (e.g., ischemia, hypertrophy, and heart failure). Excitation-Contraction Coupling and Cardiac Contractile Force &endash; Second Edition is an invaluable source of information for anyone who is interested in how the heart beat is controlled and especially suited for students of the cardiovascular system at all levels from medical/graduate students through senior investigators in related fields.

Vascular injury is initiated by oxidant injury to the vessel wall. This volume is organized around the role of oxidant damage in this disease process and provides a collection of the most recent studies, representing various disciplines that can serve as the basis for further improvements in our understanding and control of cardiovascular and cerebral vascular disease.

Our understanding of the pathophysiology of acute myocardial infarction has grown enormously in recent years. This has led to an increasingly aggressive approach to management, designed to blunt the extent of infarction by salvaging acutely ischemic myocardium. Alternatives now include throm bolysis, PTCA with and without prior thrombolysis, and emergency bypass surgery, as well as the more aggressive use of a variety of drugs. This book consists of a series of chapters by experienced cardiologists and cardiovascular surgeons that present today's state of the art in managing acute myocardial infarction. It is written with the purpose of presenting practical approaches of value to the clinician related to the more complex problems faced in dealing with patients undergoing myocardial infarction. xi EARLY INTERVENTIONS IN ACUTE MYOCARDIAL INFARCTION 1. MANAGEMENT OF ARRHYTHMIAS IN THE CORONARY CARE UNIT NORA GOLDSCHLAGER, RODERICK WOODS, AND NEAL BENOWITZ With the advent of coronary care units, mortality from cardiac arrhythmias occurring during acute myocardial infarction has been unquestionably and dramatically reduced. In addition, continuous electrocardiographic monitoring has resulted in the recognition of specific arrhythmias related to acute ischemic heart disease and thus to the development of appropriate strategies for their management. This chapter will review certain specific aspects of those bradyarrhythmias and atrial and ventricular tachyarrhythmias that are seen most commonly in acute myocardial infarction. Pharmacologic therapy, including the use of some of the newer antiarrhythmic agents, will be discussed, as will pacemaker ther apy of both bradyarrhythmias and tachyarrhythmias."

Quantitative coronary angiography has become an invaluable tool for the interventional cardiologist, providing objective and reproducible measurements of coronary artery dimensions, which can be used to study progression or regression of coronary atherosclerosis, as well as the immediate and long term effects of percutaneous interventions. Until recently, this powerful imaging technology was confined to a small number of so-called high level institutions. Fortunately, with the development of digital cardiac imaging equipment and adaptation of cine-angiographically based computer software for on-line use in the catheterization room, quantitative coronary angiography is now available to all interventionalists. This book is a timely guide for the impending QCA user, providing practical as well as theoretical and scientific information. A comprehensive evaluation of the clinical usefulness of QCA is covered, from the fundamental principles through experimental validation studies, application to clinical trials of a wide range of pharmacological and interventional therapies in the full spectrum of clinical presentation of coronary disease syndromes, evaluation of the therapeutic efficacy of various new devices for coronary intervention, together with extensive presentation of its physiological, functional and anatomical correlations, by comparison with other intracoronary measurement and imaging techniques. In addition, evolving theories and concepts in the ever topical restenosis phenomenon' after percutaneous intervention, based on serial QCA studies, are presented and discussed and a potentially unifying methodological approach to further study of this ubiquitous problem is offered. Thisbook, thanks to the collaboration of many experts in the field of intracoronary imaging and measurement, provides stimulating, interesting and practical information, both for the academic scientist and practising clinician.

Pathophysiology of Cardiovascular Disease has been divided into four sections that focus on heart dysfunction and its associated characteristics (hypertrophy, cardiomyopathy and failure); vascular dysfunction and disease; ischemic heart disease; and novel therapeutic interventions.
This volume is a compendium of different approaches to understanding cardiovascular disease and identifying the proteins, pathways and processes that impact it.

The presentation of new, emerging concepts of the pathogenesis and management of acute Myocardial Infarction is the unprecedented objective of this book. Based upon the Symposium on Acute MI, this timely text presents the advances that have taken place on several fronts in the past five years, particularly in the area related to thrombolytic therapy. Separated into four sections, the book covers the mechanisms of acute MI; medical problems of detection, sizing, and damage; non-invasive medical management; and invasive management. Of particular interest is the section on non-invasion management which focuses on the results from the TIMI Clinical Trial and the successful use of tissue plasminogen activator (tPA). Focus is also placed on the long-term follow up of patients treated with thrombolytic therapy and the no-reflow phenomenon in the stunned myocardium. A collaboration of recognized experts in their fields, this text is of extreme value to the practicing cardiologist, radiologist, surgeon and emergency care physician.

The text's first section explores the basic mechanisms of coronary artery contraction, coronary artery stenosis and vasopasm. Its second section develops the pathophysiology of acute MI including the reversibility of ischemic myocardial injury, and methods for detecting the size and extent of myocardial infarcts. The crucial role of cardiac muscle cell membrane damage is also discussed. The physiology and pharmacology of tPA are described in the third section as are the results from the initial phase 1 TIMI trial. The final section which concentrates on surgical procedures, also provides future directions for the diagnosis and treatment of acute Myocardial Infarctions.

Essentials of Cardiovascular Examination highlights common mistakes made in cardiovascular examination. The book provides a solid foundation of clinical knowledge for the beginner, and an excellent reference guide for the experienced clinician. Divided into 53 chapters across four sections, the book begins with guidance on approach to the patient, including cardiac history, general examination, and the anatomy of the heart and coronary circulation. The second section covers the cardiovascular system in detail, with topics including pulse, blood pressure, and percussion of the heart. The third section covers diseases relating to the cardiovascular system, ranging from congenital heart disease to ischemic heart disease and arrhythmias. The final section covers different investigations of the cardiovascular system, including the electrocardiogram, non-invasive imaging, stress tests and cardiac catheterisation. With 70 images, illustrations and information tables, Essentials of the Cardiovascular System covers anatomy and physiology, physical diagnosis of all common cardiovascular diseases, their investigation and treatment, making this an ideal resource for students preparing for examinations. Key Points Concise guide to anatomy, physiology, physical diagnosis of diseases, investigation and treatment 70 illustrations, images and information tables Ideal for students preparing for examinations Excellent reference guide for experienced clinicians

In 1981 Dr Jean Lintermans published, with Dr van Dorp, a superb vol ume, 'Differential Diagnosis in Pediatric Echocardiography'. It was 'state of the art' with a unique organization, starting with M-mode echocardiograph ic findings rather than the disease category, and included a segmental approach to diagnosis, and concluded with an invaluable section on normal echocardiographic values. This volume was a great help to many of us in pediatric cardiology who were discovering the great clinical value of the noninvasive approach to diagnosis. This gave us a 'running start' for our own entry into the field. At that time, the 2 D or sector echocardiogram was finding increasing usefulness and there were several illustrations of this tech nique, integrated into that volume. Since 1980, the field of 2 D echocardiography has grown enormously in its usefulness, to the point that it has reduced the need for invasive studies, and has enhanced the precision of invasive studies when required. It is now time for a systematic and thorough approach to this field, and I am delighted that Jean Lintermans has provided us with this book. The pictures are uniformly superb and are very well labelled. The organization is cen tered around diagnostic categories, but the same attention to detail is pre sent that made the first volume so useful. I particularly value the extensive documentation of diagnostic findings, with numerous literature citations."

In 1982, as chance would have it again, an opportunity appeared to Jom the Department of Physiology at Kuwait University. P. Braveny spend four years there, teaching, doing some research, recovering former international contacts. Coming back home, he faced the same gloomy, motionless disfavor as before. November 1989 turned P. Bravenfs career upside down. Immediately after the fall ofthe communist regime, he was elected vice-dean and later dean ofthe Faculty of Medicine, promoted full professor in physiology and appointed the head of the Department ofPhysiology. From 1992 to 1998 P. Braveny served as the vice-rector of Masaryk University. His professional career culminated in his presidency of the XIV World Congress of ISHR in Prague. Understandably, in the following years, he become interested (in his tutor's footsteps) in history of physiology and pub- lished two monoghaphs (E. Babak andV Kruta). This CV would be an incomplete one without mentioning his broad interests in natural sciences and in art, particu- larly music and painting. As a tutored amateur he has acquired certain success in the latter. When reviewing P. Bravenfs whole-life work, largely done under adverse cir- cumstances with minimum financial support, his almost two hundred papers, innu- merable essays and four monographs are a commensurate result. In appreciation, he was awarded honorary membership of the Czech Medical Society, Physiological Society and Cardiological Society, Gold Medal of Masaryk University, Ministry of Education Award etc. Bohuslav Ostadal Makoto Nagano Naranjan S.

Interest in the ability of myocardium to adapt to ischaemic stress has continued to grow since the discovery of ischaemic preconditioning in 1986. In 1993, two reports heralded the recognition of a delayed preconditioning response in the heart, now commonly known as the second window' of protection. Since then, a number of studies have described the ability of delayed preconditioning and related adaptive phenomena to protect against a variety of pathologies in the ischaemic and reperfused myocardium. Our understanding of the cellular mechanisms of sub-acute adaptive cardioprotection has advanced considerably during this period. This compilation of state-of-the-art reviews by those who have made significant contributions to this field provides detailed and critical analysis of this research, from molecular basis to potential clinical relevance. The book aims to provide an authoritative, comprehensive and thoroughly up-to-date overview for scientists and clinicians engaged in, or observing, this rapidly-developing area of heart research. It will also be of interest to those engaged in research on other tissues where ischaemia-reperfusion pathology is of major concern.

The Frontiers in Cardiovascular Health varies between and within nations, depend ing upon the level at which the battle is fought for better cardiovascular health. According to the 1997 World Health Report, 15 million deaths (i. e. 30% of the total number of deaths) were attributable to cardiovascular diseases and this number is on the rise. The projection for the year 2020 is quite alarming with an expected cardiovascular mortality reaching 50 million. Much of this burden is projected to occur in developing countries, more specifically in the most populous countries of the world, namely China and India. These countries are already burdened with infectious and parasitic diseases and are trying to eradicate such diseases. With increasing life expectancies people all over the world, especially in developing coun tries, are exposed to degenerative atherosclerosis resulting in increased cardiovascu lar mortality and morbidity. In developing countries, resources available for health care are very limited. For example many of the African countries spend less than $10 per person per year on his/her entire health care let alone cardiovascular health. The average health care budget for nearly two thirds of the global population is well below $100 per year, on a per capita basis. Therefore, in developing countries health promotion and primary prevention are the frontiers by necessity. Improving awareness and health education is not only a matter of choice but is an absolute necessity.

In the last ten years, major strides have been made in defining the presence and role of inflammation in atherosclerosis as well as in injury to the tissues that occurs after episodes of ischemia and reperfusion. In sixteen chapters, written by world-renowned individuals from different countries, the role of inflammation and different mediators in the pathogenesis of atherosclerosis is presented. The significance of inflammation and possible therapeutic implications is also described in depth. This book is of great interest for a wide range of physicians, researchers, and scientists who may want to study more and develop the concept of inflammation and atherosclerosis.

This volume provides comprehensive protocols that researchers can use to dissect out fundamental principles and molecular mechanisms of hypertension, extending from genetics of experimental hypertension to biomarkers in clinical hypertension. Hypertension: Methods and Protocols guides readers through chapters on genetics and mmics of hypertension; the Renin-Angiotensin-Aldosterone System; vasoactive agents and hypertension; signal transduction and reactive oxygen species; novel cell models and approaches to study molecular mechanisms of hypertension; vascular physiology; and new approaches to manipulate mouse models to study molecular mechanisms of hypertension. Written in the highly successful Methods in Molecular Biology series format, chapters include introductions to their respective topics, lists of the necessary materials and reagents, step-by-step, readily reproducible laboratory protocols, and tips on troubleshooting and avoiding known pitfalls. Authoritative and cutting-edge, Hypertension: Methods and Protocols aims to ensure successful results in the further study of this vital field.

Biology of the Arterial Wall is intended as a general reference text concerned with the biology of the vascular cells and the blood vessel wall under physiological and pathological conditions. One of the major functions of the arteries is to maintain a continuous blood flow to the organs whatever the pressure conditions, thanks to the vasomotor tone of the smooth muscle cells. Great advances have been made over the last decade in the understanding of the endothelial cells as integrators and transducers of signals originating from the blood stream. The pluripotent control functions of the endothelial cells in the vessel wall are now well recognized. A review of endothelial functions and dysfunctions is presented. Cell biology and molecular genetic studies have now identified an array of molecules elaborated by endothelial cells and vascular smooth muscle cells and by the blood-borne elements which interact with artery cells, defending the artery against injury and modulating evolving abnormal processes. Molecules which induce or inhibit endothelial and/or smooth muscle cells are currently under great scrutiny. Angiogenesis, which plays a major role in tumor growth, but may also be beneficial as a healing process in muscle ischemia, is discussed. Apoptosis, or programmed cell death, has only recently been recognized as an essential process in blood vessel modeling and remodeling. An overview of apoptosis in the vascular system is presented. It is increasingly evident that the adjustments of the blood vessel wall are made in the presence of deforming disease processes such as hypertension and atherosclerosis. The second part of the book is concerned with the blood vessel wall in disease conditions. Several chapters review the role of the vessel and vascular cells in inflammation, and vascular remodeling during arterial hypertension and aging. One chapter is devoted to atherogenesis, atheroma and plaque instability, followed by the pathophysiology of post-angioplasty restenosis, which is a crucial issue in modern interventional cardiology.

Over two centuries ago, oxygen was discovered as "air vital" the component of the earth's atmosphere necessary for life. Less than five years after this discovery, it was found that oxygen was both a life-sustaining and life threatening inhalant as it plays a role in the two extremes of the animal kingdom: life and death. In the subse quent years, we have made major strides in understanding the role of oxygen in maintaining life and volumes of information are now available on this topic. Our knowledge of the contribution of oxygen in cellular dysfunction and cell death which for the most part had lagged behind has begun to catch up. The deleterious ef fects of oxygen radicals and activated oxygen species on a variety of biological systems have now been described. Recently attention has also been focused on the toxic effects of oxygen on the cardiovascular system. The major aim of the present treatise is to offer an integrated view of the pathophysiological aspects of oxygen toxicity in the heart and blood vessels coupled with a review of therapeutic approaches (hopes?) with free radical scavengers and antioxidants. Internationally known expert investigators provide a concise and critical review on the topic of their expertise which also contains data from their own research."

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 multidetector CT scanner speeds diagnosis and treatment of patients. One of its many uses is to perform CT coronary angiography. Multidetector CT has generated excitement within the cardiology and radiology community as it provides clear pictures and takes less time than other non-invasive techniques, including conventional spiral and electron-beam CT which can take up to an hour or more. This atlas presents over 160 illustrations, with 116 in color and illustrates the capacity of multidetector CT for the analysis of the anatomy of the coronary arteries.

In Harch of 1980, we organized the first symposium on how to evaluate new antiarrhythmic agents in which the participants included members of the Cardio-Renal Division of the Food and Drug Administration, academic investigators from the United States and Abroad and directors and imple mentors of pharmacological research representing the pharmaceutical industry. By bringing together all three elements, it was hoped that better communication and under standing would ensue to more rapidly bring new cardiac agents to the American public. This goal was important since a rather limited number of antiarrhythmic agents were and are currently available to treat patients with such disorders in the United States. These agents are needed not only for the treatment of patients with sustained ventricular tachyarrhythmias which produce life-threatening hemodynamic consequences but also and in fact more potentially important as a prophylactic measure in the high risk patient subject to sudden cardiac death. This book represents the proceedings of the third of these Symposiums whose purpose was to evaluate the clinical research methodology and models used in the evaluation of ne" antiarrhythmic agents for not only acute therapeutic inter vention but also for the prophylaxis of sudden cardiac death. In addition, new devices have evolved over the past few years that can detect and treat life-threatening cardiac arrhythmias and the evaluation of efficacy and safety of these devices is detailed."