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CARDIAC VALVE ALLOGRAFTS (HOMOGRAFTS) highlights the current
controversy about freehand subcoronary aortic valve and root
replacement with regard to postoperative morbidity and long term
durability. It discusses particular implantation techniques of
preference in young patients and in different root pathology. Other
chapters address intermediate- and long-term results on cardiac
valve and vascular homografts for treating complicating cardiac
valve and aortic infections. The chapter on basic science
additionally makes this book a highly authoritative reference
source for cardiac surgeons, physicians and scientists. This work
provides a current survey of the state-of-the-art.
Cardiac surgery has developed dramatically since the first open-he
art operations were performed in the mid 1950s. Although the
improvement of surgical technique, extracorporeal circulation, and
postoperative management has contributed to a marked reduction of
morbidity and mortality, the development of cardiac surgery to its
present state would not have been possible without blood
substitution by homologous donor blood. Only 20 years ago,
open-heart operations required an average of 8 units of blood
preserves. The excessive need of donor blood in those early days
was mainly due to premature surgical technique, insecure control of
anticoagulation, severe blood trauma by extracorporeal circulation,
and the lack of retransfusion technologies that would have allowed
the reuse of shed mediastinal blood. The introduction of new
technologies, such as normovolemic hemodilution, in traoperative
autotransfusion, postoperative return of shed mediastinal blood,
and predonation of autologous blood has greatly reduced donor blood
requirements. At present the majority of routine coronary artery
surgical procedures can be performed without any blood transfusion.
Blood loss, however, may be considerable in patients undergoing
complex valve surgery or reoperations, as they often require
several units of transfused blood. Blood conservation has now
become an area of major interest for the cardiac surgeon. This
increased concern is caused by infectious complications of blood
transfusion, in particular hepatitis and, more recently, AIDS."
The International Symposium on Ischemic Mitral Incompetence was
held December2-4,1988 at the Intercontinental Hotel, Berlin . It
wasorganized bythe German Heart Center Berlin with the primary aim
to bring together experts interested in the subject of ischemic
mitral regurgitation. Our intention was to face the problems
associated with diagnosis and treatment of mitral incompetence
resulting from coronary artery disease. A "work-up" of the whole
topic from its basic, diagnostic, and surgical aspects
wasinitiated. In the first section weconcentrate on the basic
anatomical and pathophysiological knowledge, as well as on
experimental work. In the second section cardiologists report on
inci- dence of ischemic mitral incompetence, diagnostic methods
that include esophageal echocardiography, follow-up studies of
medical- and surgical-treated patients. This section considers
interventional therapy in acute myocardial infarc- tion, as well.
The third section includes contributions by cardiac surgeons with
many years' experience in operative treatment of ischemic mitral
incompetence including the decision-making criteria for non-mitral
valve surgery, and for valve reconstruction or replacement.
After decades of laboratory investigations mechanical circulatory
support for the failing heart has entered the clinical arena.
Today, a growing number of patients with progressive myocardial
failure awaiting cardiac transplantation is successfully bridged to
transplantation with ventricular assist devices. The proceedings of
the "Mechanical Circulatory Support"-meeting, held in Berlin,
October 21-22, 1995, present new aspects of mechanical circulatory
support, recent experience with MCS in newborns and children using
specially developed small devices, and the results of long-term
mechanical assistance. The ability of the myocardium to recover
under pressure de-loading and reduced workload is discussed. All
these topics open up new perspectives for the use of mechanical
circulatory support, not only as a bridge to transplantation, but
also as a definitive approach for treating patients with end-stage
heart failure. Some of these concepts may even provide real
alternatives to heart transplantation, these being sorely needed in
light of the severe donor organ shortage. Regulatory as well as
ethical aspects of the extended use of mechanical circulatory
support systems and new technical developments in the field are
discussed by internationally distinguished experts.
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."
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