Direct surgery on arteries was born at the turn of the nineteenth and twentieth century. However, it was only during the last twenty-four years, that this new chapter of clinical surgery could be weil established, owing to diverse kinds of minds and hands. The result is that limbs, organs, functions, and lives have since then been saved in increasing numbers. We may now consider that the main impulse of this new phase is over. But the material of wh ich the chapter was built is still defective, incomplete, or inadequate, and therefore surgeons and many other men will still have to spend a lot of sagacity and vigour to give this chapter its proper arrangement. Principles evolve, methods are modified as a result of technical progress, surgeons' solid opinions on a particular matter give way to other distinct but equally solid opinions on the same matter. These are the reasons why the moment we are living in is a wonderful one. As always in Iife, the great flame burns more intensely when one finds himself at the verge of attaining so me proposed design. The first phase of dream and failure has given way to a more structured ground on wh ich the final battle must be fought. Such a battle is taking place right now.

Cardiovascular Biomaterials presents current research mate- rial developed by contributors from universities und profes- sional laboratories in the UK, USA, Canada, and Germany, each recognised for their abilities in this field.The book begins with an introduction to the work of developing a new artificial artery, and proceeds through the topics of the problems and developments in heart valve replacements, car- diac assist devices, mechanical properties of arteries and arterial grafts, biostability of vascular prostheses, blood compatibility in cardiopulmonary bypass, collagenin cardio- vascular tissues and the pacemaker system. Researchers, practitioners, graduate students, and libraries will find the book of interest.

It was the genius of Gordon Murray in Toronto that introduced the use of allografts into cardiac surgery in the 1950s. Soon after this on opposite sides ofthe world, Sir Brian Barratt-Boyes in Auckland, New Zealand, and Mr. Donald Ross in London, undertook to use allografts for the replacement of diseased aortic valves. Since that time the global interest in allografts has been patchy, episodic, and without a con sensus. Nonetheless, for the last 20 years at least three groups in the world have steadfastly pursued the development of new and relevant information concerning the use of allograft valves in humans. These are the centres of Sir Brian Barratt Boyes, Mr. Donald Ross, and Mark O'Brien in Brisbane. More recently, talented investigators, including Drs. Yankah, Yacoub, and others, have been developing information concerning the immunological aspects of the use of allografts, as well as their clinical use. No doubt, at present, cardiac valve allografts of one sort or another are the devices of choice for conduits and have an important place in the surgery of aortic valve replacement. Even so, in the mind of this writer at least, the future usefulness of allografts for the replacement of diseased cardiac valves and conduits between a ventricle and the pulmonary artery, remains problematic, and depends upon improvements in other devices for this purpose and upon improve ments that may be made in preparing and using allografts."

Since the advent of microsurgery, there has always been a need for a systematic presentation of relevant anatomical biometry. In view of this urgent demand, this monograph has been compiled on the basis of recent research done by Chinese colleagues in the fields of microsurgery and related anatomical sciences from more than fourteen medical colleges in the hope of providing a complete set of anatomical data covering most areas of modern microsurgery. This volume presents thirteen chapters dealing with the applied anatomy of free skin flap, muscle, bone and omental grafting and of intestinal and small organ transplantation including reconstruction of the thumb using toes. Space is also devoted to the microsurgical anatomy of the central and peripheral nervous systems, the lymphatic system and the middle ear. To help under standing, 212 illustrations, involving 21 photographic plates, are included. The authors are particularly indebted to Professors He Guangchi and Zhao Minxue for their valuable suggestions and revision of the manuscript, and also to the late Professor Yang Dongyue for his personal contribution in the field of microsurgery and everlasting inspiration. The authors also wish to express their gratitude to the publishers for their great enthusiasm in producing this first edition."

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.

Coronary heart disease is one of the major health problems in indus trialized nations because of its high incidence and severity. Recent innovations in medical and surgical treatment of coronary heart dis ease have increased the importance of accurate diagnostic methods for determining the severity of coronary disease, identifying potential treatment alternatives, and evaluating the results of treatment. Great advances have also been made in basic research on coronary circula tion and its interaction with myocardial contraction and relaxation and neural and humoral control. With respect to these developments, the papers included in the present monograph deal with important topics concerned with the basic mechanism of coronary circulation as well as ones of clinical relevance. It is directed toward physicians (cardiologists, cardiac surgeons, cardiac radiologists, anestheologists, and others) and basic scientists (e.g., physiologists, bioengineers). We would like to em phasize the importance of a multidisciplinary approach in which basic scientists and clinicians work closely together. This volume consists of nine chapters. Chapter 1 contains macro scopic and microscopic descriptions of coronary vascular anatomy, which is closely related to the functions of coronary circulation. In Chap. 2 two methods in current use to evaluate phasic coronary blood velocity waveforms are presented, i.e., the laser Doppler and ultrasound Doppler methods. Chapter 3 describes the mechanical properties of coronary circulation, a knowledge of which is indispens able for an understanding of coronary arterial and venous blood flow velocity waveforms in relation to cardiac contraction and relaxation."

Cardiovascular disease, the leading cause of With increased experience using the inter- death in industrialized societies, not only nal mammary artery, these groups of sur- strikes down a significant fraction of the geons eventually applied the procedure to a population without warning, but also causes larger population of patients. Eventually, prolonged suffering and disability in even the mammary artery was used in sequential larger number. Until the development of fashion to bypass more than one artery, and, heart surgery and the introduction of diag- in some patients, both mammary arteries nostic techniques including cineangiogra- were used. Using these new techniques, sur- phy, stress electrocardiography, echocardio- geons could bypass almost every area of the graphy, and myocardial scanning, the diseased coronary system except the distal treatment of arteriosclerotic heart disease circumflex branches and distal right branch- was confined to medical measures that were es. Then, in 1983 and in 1985, Campeau and usually only partially effective. Lytle published the results of their long-term After the introduction of selective coro- studies of mammary artery bypass. These nary angiography by Sones, surgeons, led by important reports showed significantly dif- Favaloro and Johnson, began to apply the ferent results in favor of the internal mam- principle of bypass to coronary arterial dis- mary artery over the saphenous vein graft. ease.

Based on the research and clinical work presented at the Fifth International Symposium, Vascular Surgery 1991, this book gathers forty contributions from renowned clinicians and researchers and outstanding young investigators around the world.

This volume contains the revised texts of the presentations at the 29th International Congress of the European Society of Cardiovascular Surgery, held from July 2-5, 1980, in Dusseldorf under the presidency of Jan Nielobowicz (Warsaw). We express our gratitude to all the authors who have been partici- pating in the Congress, in particular to the invited speakers A. R. Castaneda (Boston), D. B. Effler (Syracuse), F. Fontan (Bordeaux), F. Robicsek (Charlotte), and D. N. Ross (London) for their cooperation. We are grateful to our colleagues of the Surgical Department B at the University of Dusseldorf, J. A. Herzer, G. Irlich, R. Karfer, and A. Krian, for their help during preparation and organisation of the Congress. Finally, we are indebted to Sanol Schwarz GmbH for its support of this publication. Dusseldorf, June 1981 Wolfgang Bircks Jarg Ostermeyer Hagen D. Schulte Contents The Contribution of European Surgeons to the Development of Modern Vascular Surgery. J. Nielubowicz. With 20 Figures *. ****** Session I Cardiac Surgery Valvular Surgery I Chairman: V. O. Bjork, Stockholm; Co-Chairman: A. Carpentier, Paris Special Morphological Structures Along the Closing Zone of the Mitral Valve. H. Heine and M. Laatz. With :5 Figures **. **. . *. *. . ** 25 Conservative Surgery of the Mitral Valve. Annuloplasty on a New Adjustable Ring. M. Puig Massana, J. M. Calbet, and E. Castells With :5 Figures ********. **. *****. **. ****. *****************...*.

This atlas offers a collection of EEG spectral analyses and their corresponding conventional recordings under anes thesio10gical procedures. The EEGs presented here were re corded on general surgical and gynecological patients during the last few years. Premedication, induction and maintenance of anesthesia, recovery the immediate postoperative period, and intensive care are covered. Techniques for operating the necessary equipment and artefacts relevant to the routine clinical use of EEG are briefly outlined. Typical examples of characteristic EEGs are presented at the beginning of each chapter, followed by illustrations of deviations from the norm showing the great variety of anesthesiologically induced changes of cerebral function. The description of each EEG course is assessed in relation to clinical parameters. Sometimes no satisfactory interpreta tion can be made, because many physiological and patho physiological causes of alterations in cerebral function are unknown. Time and again it proves impossible to estimate wether deviations from the norm have their origin in cerebral changes or are secondary to extracerebra1 disturbances. The atlas comprises a complete survey in itself, but it can also be seen as a supplement to the book The Electroenceph alogram in Anesthesia by I. Pich1mayr, U. Lips, and H. Kunkel (Springer, 1983), in which detailed lists of references are quoted that are omitted here."

Assisted Circulation 4 is an authoritative review of the progress which has been achieved in the last 5 years since the publication of "Assisted Circulation 3" in 1989. The present book highlights the work of well-known experts on indications for assisted circulation, cardiac support devices such as bridges, devices for transplantation, devices for chronic mechanical support, biological energy sources, cardiomyoplasty, extracorporeal membraneoxygenation and an overview of cardiac devices support with a specific emphasis on xenotransplantation. Assisted Circulation 4 is the latest product of an ongoing effort by the editors to keep readers regularly informed of recent developments in the field. Assisted Circulation is a standard technology in cardiac surgery and especially in cardiac transplantation.

In textbooks on anatomy, radiology and stead of the normal one. An "accessory ar- surgery only the "normal" arterial blood tery" is a second artery ip addition to the one normally present, without any specifi- supply is usually described. This "nor- mality", however, is sometimes found in cation of size being made. However, there less than 30% of all cases for some arteries, is no general agreement on whether minute but in over 95% for others. Rarely men- vessels with very small diameters and hard- tioned are deviations in the individual ar- ly any significant blood flow should also be tery's origin, topographical localization and considered. the area it supplies. They can be classified The aims of this book were twofold: first, to into two groups: malformations and vari- extract the frequency of arterial anomalies from the literature (often published in inac- ations. Malformations often have a nega- tive influence on the function of the organ cessible journals) and second, to classity under normal circumstances, e.g. if both these arteries by schematic outlines of the basic types.

Use of the implantable cardioverter/defibrillator is the most significant advance in the management of patients with life- botn threatening cardiac arrhythmias. This device represents an important practical as well as conceptual breakthrough in arrhythmia management. It places on firm footing use of non-pharmacologic tools for clinicians. The text, Implan- table Cardioverter/Defibrillator, represents contributions by the leading clinicians in this field from both sides of the Atlantic and is a welcome addition to the library of clinical electrophysiologists as well as cardiac surgeons. The editors have well collated the critical issues related to current use of device therapy in a meaningful and practical fashion. The text amply reminds us that we are in the early growth phases of a technology that promises to completely change our approach to the cure of patients with actual or potentially life-threatening ventricular dysrhythmias. It also reminds us that Dr. Mirwoski's dream continues to live and remains as a perpetual challenge to clinicians and engineers alike to bet- ter perfect and utilize device therapy for our patients. I com- mend the authors and editors for a superb and timely effort. San Francisco, CA, USA Melvin M. Scheinman, M. D. Preface 1teatment of patients with ventricular tachycardia and pre- vention of sudden arrhythmic death is one of the most challenging tasks of modem cardiology. 'len years ago anti- arrhythmic drug therapy was the medical tool used most fre- quently in the management of patients with life-threatening ventricular tachyarrhythmias.

Assisted Circulation 3 is an authoritative review of the progress which has been achieved in the last 5 years since the appearance of Assisted Circulation 2 in 1984. The present book highlights the work of well-known experts on - new indications for assisted circulation, - cardiac assist devices as bridges toward transplantation, - temporary mechanical heart support, - results of long term studies into problems of tissue overgrowth, infection, and physiological regulation of cardiac devices, and - new results on cardiac transplantation and the new immunsuppresive regima. Assisted Circulation 3 is the latest product of an ongoing effort by the editors to keep readers abreast of recent advances in the field on a regular basis.

"Rate Adaptive Cardiac Pacing" provides a comprehensive overview of this most advanced form of stimulating the heart by means of cardiac pacemakers that vary the pacing rate according to the needs of the patients. The heart rate is controlled by one or several sensors that detect various parameters such as respiration, blood temperature, oxygen saturation, intracardiac pressure, QT interval, stroke volume andbody activity. Besides describing the clinical and functional characteristics of these various sensors, the book also gives a clear understanding of hemodynamic aspects and in particular, all clinical issues of importance such as indications for rate adaptive pacing and selection of the appropriate patients for rate adaptive pacemakers, with many ECG samples. The book also covers new concepts in rate adaptive pacing such as single lead atrial synchronous pacing and the combination of various sensors, which are among the most recent developments in the field. With contributions from the most wellknown experts in the field from allover the world, this book is the first publication to cover all the hemodynamic, clinical and technical aspects of rate adaptive cardiac pacing.

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.

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.

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

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

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

Herewe offer anew approach to understanding and managing common medical conditions. With the needs of our readers in mind we present clearer, more extensive and more expansive views on them. Traditional medical textbooks are wordy tomes with well worn patterns dealing in set order with 'causes, symptoms and signs, diagnosis and treatment'. They offer formal instant snapshots of diseases. We have devised an economic synoptic style, and we have endeavoured to give acomprehensive and an on-going long term movepicture ofeach condition and to relate this to the analysisofsymptoms and signs, to diagnostic assessment and to management and treatment. We have selected 22 important conditions and for eachhave followed the same sequence of questions and answers: * What is it? giving a brief summary of the current understanding of the nature of the condition. * Who gets it when? showing the age-sex distributions and influence ofother factors such as social class, international comparisons, andtheirlikelyfrequency ingeneralpractice and at the district general hospital. * What happens? analysing the significance of symptoms and signs, the likely course and outcome and how these influence care. * What to do? an appreciation of the nature and presentation of the condition, and their relevance to diagnosis and management.

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

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

With contributions by D. Albrechtsen, O.H. Bentdal, H. Bondevik, I.B. Brekke, P. Fauchald, J.G. Fjeld, A. Flatmark, A. Foss, A. Hartmann, H. Holdaas, R. Innes, A. Jakobsen, N.E. Klow, B. Lien, O. Oyen, P.F. Pfeffer, K. Rootwelt, G. Sodal and K. Vatne

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