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

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

When the external Quinton-Scribner arteriovenous shunt was developed in 1960, and, a little later, the internal Brescia-Cimino arteriovenous fistula was developed as a vascular access for hemodialysis, thereby making possible regular dialysis therapy of chronic uremic patients, many nephrologists became surgeons, having learned the type of vascular surgery related to hemodialysis quite well. The same series of events occurred with regards to peritoneal dialysis with the introduction of the Tenckhoff catheter and the need for gaining a permanent access to the peritoneum for chronic ambulatory peritoneal dialysis (CAPD) therapy. With time, however, problems relating to vascular and peritoneal access have forced many nephrologists to give up their surgery; meanwhile, many surgeons have become quite expert in some sophisticated techniques relating to dial ysis (e. g., vessel grafting, prosthesis implantation, etc.). Today, whether or not involved in this type of surgery, both nephrologists and surgeons remain interested in knowing all available access devices for dialysis as well as the surgical techniques involved. However, all nephrologists involved in dialysis must know how to prevent or treat complications related to dialysis access. Thus, it appeared to me to be quite advisable to have a book in my series, Topics in Renal Medicine, dealing with vascular and peritoneal access for dialysis.

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.

Diagnostic and therapeutic methods and controversies in the management of renovascular hypertension have undergone major ch- ges during the past few years. This book is based on the proceedings of a successful postgraduate Boerhaave Course held in 1982 at the Faculty of Medicine of the University of Leiden, The Netherlands. Current concepts concerning the diagnosis and treatment of reno vascular hypertension were presented during this course to an audience composed of physicians, nephrologists, cardiologists, surgeons, uro logists, and radiologists. Thus, this book aims at offering an overview of tho, se aspects of renovascular hypertension which are relevant to clinical pr- tice. An effort is made to review the currently available moda lities of diagnostic procedures, both on the basis of modern in sights in the pathology and pathophysiology of renovascular hyper tension, as well as timely r'esul ts of clinical research. In ad dition, several chapters deal with combinations of these di- nostic procedures in a fashion that can be of practical help in clin;cal decision making. The medical, surgical and angioplastic modalities of treatment are reviewed. Basic considerations concerning medical treatment and technical aspects of surgical as well as per cutaneous angioplasty are presented in detail, both separately and in combination. Special attention is given to the problem of renal artery stenosjs in k dney transplants. This book offers up to date information on clinical aspects of renovascular hypertension, useful to a wide range of clinicians in a variety of disciplines."

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.

Varicose veins are a very common problem. The precise aetiology of primary varicose veins remains unclear. It seems likely from the available evidence that inherited structural weakness combined with haemodynamic or microcirculatory abnormalities eventually lead to reduced vein wall elasticity, dilatation and the formation of varicosities. Increasing age, female gender, parity and occupation may all promote the development of varicose veins in susceptible individuals. Further clinical and experimental studies are necessary if the relative contribution of each of these factors is to be fully elucidated. References 1. Editorial. The treatment of varicose veins. Lancet 1975;ii:311. 2. Prerovsky I. Diseases of the veins. World Health Organisation, internal communication, MHO-PA 10964. 3. Weddell JM. Varicose veins: pilot study. Br J Surg 1969;23:179-186. 4. Hobsley M. Pathways in surgical management. 2nd ed. London: Edward Arnold, 1986. 5. Browse NL, Burnand KG, Lea Thomas M. Diseases of the veins. London: Edward Arnold, 1988. 6. Logan WPD, Brooke EM. The survey of sickness. Studies on medical and population subjects no. 12. London: General Register Office, 1957. 7. The committee on the Danish national morbidity survey. The sickness survey of Denmark. Copenhagen, 1960. 8. US Department of Health. Education and welfare: national health survey 1935-1936. Washington, DC, 1938. 9. The Department of National Health and Welfare and the Dominion Bureau of Statistics. Illness and health care in Canada. Canadian Sickness Survey 1950-1951. Ottawa, 1960.

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

Spinal Cord Stimulation II (SCS) contains the state of the art of this innovative method in the treatment of peripheral vascular disease.
The volume presents such topics as: Spinal Cord Stimulation for Chronic Pain.- Management of Critical Limb Ischemia.- Spinal Cord Stimulation for Angina Pectoris.- Buerger's Disease.- Miscellaneous.

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

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

Over the past 15 years, a multitude of new transluminal techniques have been developed, all designed to broaden the range of indications and improve the results of angioplasty. Among these, the implantation of intravascular stents has emerged as the technique with the greatest promise. It has become clear that stenting not only successfully deals with the problem of abrupt closure after angioplasty, but also reduces the incidence of restenosis, the Achilles heel of angioplasty. The reason why restenosis is reduced may be because the immediate gain of luminal diameter is greater with stenting than with any other technique. Even if the late loss of diameter is similar among most currently used transluminal techniques, the end result will stilI be better after stenting because of the nearly ideal primary effect. The aims of this book are twofold: first it presents a state-of-the-art summary of the progress made in stenting so far, and secondly it details some of the prospects for future improvement. The concept of stenting has proved to be a correct one, and therefore alI future efforts wilI be directed towards new, safe, and biologicalIy "friendly" stents.

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.

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

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

A comprehensive review of current endovascular techniques for the treatment of cerebral aneurysms, this is a practical manual for those practicing, or intending to practice, this rapidly expanding branch of minimally invasive surgery. The authors provide descriptions based on an extensive combined experience of clinical management, technical problems, complications and recent results, and discuss the limitations and role of combined extravasular/endovascular techniques.

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.

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

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.

Among the many intense light sources, excimer lasers have a unique set of properties that place them at the forefront of tooling for material processing. Their extreme versatility means that they can be used in many areas of materials science and medicine. But three conditions need to be fulfilled in order that their versatility be truly appreciated and exploited: the characteristics and limitations of the sources must be known; the basic excimer laser processes should become reasonably widely known; and problems in search of a solution should be clearly identified. Excimer Lasers covers all three of these points in an instructive and logical way. Probably for the first time, both instrumental and fundamental aspects of excimer laser interaction with matter are presented side-by-side, with examples drawn from the widest range of materials. The articles gathered here are tutorial in their nature, thus making them suitable for a wide readership, from recent graduates and postgraduate students to those established scientists entering the field, all of whom could not find a better, nor more authoritative work with which to start their reading.

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

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