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Surgery_Schwartz_5302 | Surgery_Schwartz | repair of total anomalous pulmonary venous con-nection. Thorac Cardiovasc Surg. 2001;49(2):101-106. 84. Bando K, Turrentine MW, Ensing GJ, et al. Surgical man-agement of total anomalous pulmonary venous connection. Thirty-year trends. Circulation. 1996;95(9 suppl):II12-II26. 85. Karamlou T, Gurofsky R, Al Sukhni E, et al. Factors associated with mortality and reoperation in 377 children with total anomalous pulmonary venous connection. Circulation. 2007;115(12):1591-1598. This article describes the era-specific changes in the incidence of mortality and reoperation in children with total anomalous pulmonary venous connection and describes the unfavorable anatomic characteristics that determine postrepair survival. 86. Salomone G, Tiraboschi R, Bianchi T, Ferri F, Crippa M, Parenzan L. Cor triatriatum: clinical presentation and operative results. J Thorac Cardiovasc Surg. 1991;101(6):1088-1092. 87. Huang TC, Lee CL, Lin CC, Tseng CJ, Hsieh KS. Use of an Inoue balloon dilatation method | Surgery_Schwartz. repair of total anomalous pulmonary venous con-nection. Thorac Cardiovasc Surg. 2001;49(2):101-106. 84. Bando K, Turrentine MW, Ensing GJ, et al. Surgical man-agement of total anomalous pulmonary venous connection. Thirty-year trends. Circulation. 1996;95(9 suppl):II12-II26. 85. Karamlou T, Gurofsky R, Al Sukhni E, et al. Factors associated with mortality and reoperation in 377 children with total anomalous pulmonary venous connection. Circulation. 2007;115(12):1591-1598. This article describes the era-specific changes in the incidence of mortality and reoperation in children with total anomalous pulmonary venous connection and describes the unfavorable anatomic characteristics that determine postrepair survival. 86. Salomone G, Tiraboschi R, Bianchi T, Ferri F, Crippa M, Parenzan L. Cor triatriatum: clinical presentation and operative results. J Thorac Cardiovasc Surg. 1991;101(6):1088-1092. 87. Huang TC, Lee CL, Lin CC, Tseng CJ, Hsieh KS. Use of an Inoue balloon dilatation method |
Surgery_Schwartz_5303 | Surgery_Schwartz | triatriatum: clinical presentation and operative results. J Thorac Cardiovasc Surg. 1991;101(6):1088-1092. 87. Huang TC, Lee CL, Lin CC, Tseng CJ, Hsieh KS. Use of an Inoue balloon dilatation method for treatment of cor triatriatum stenosis in a child. Catheter Cardiovasc Interv. 2002;57(2):252-256. 88. Cooley DA, McNamara DG, Latson JR. Aorticopulmonary septal defect: diagnosis and surgical treatment. Surgery. 1957;42(1):101-120. 89. Scalia D, Russo P, Anderson RH, et al. The surgical anatomy of hearts with no direct communication between the right atrium and the ventricular mass—so-called tricuspid atresia. J Thorac Cardiovasc Surg. 1984;87(5):743-755. 90. Cheung HC, Lincoln C, Anderson RH, et al. Options for surgical repair in hearts with univentricular atrioventricular connection and subaortic stenosis. J Thorac Cardiovasc Surg. 1990;100(5):672-681. 91. Gross RE. Surgical relief for tracheal obstruction from a vas-cular ring. N Engl J Med. 1945;233:586-590. 92. Sade RM, Rosenthal | Surgery_Schwartz. triatriatum: clinical presentation and operative results. J Thorac Cardiovasc Surg. 1991;101(6):1088-1092. 87. Huang TC, Lee CL, Lin CC, Tseng CJ, Hsieh KS. Use of an Inoue balloon dilatation method for treatment of cor triatriatum stenosis in a child. Catheter Cardiovasc Interv. 2002;57(2):252-256. 88. Cooley DA, McNamara DG, Latson JR. Aorticopulmonary septal defect: diagnosis and surgical treatment. Surgery. 1957;42(1):101-120. 89. Scalia D, Russo P, Anderson RH, et al. The surgical anatomy of hearts with no direct communication between the right atrium and the ventricular mass—so-called tricuspid atresia. J Thorac Cardiovasc Surg. 1984;87(5):743-755. 90. Cheung HC, Lincoln C, Anderson RH, et al. Options for surgical repair in hearts with univentricular atrioventricular connection and subaortic stenosis. J Thorac Cardiovasc Surg. 1990;100(5):672-681. 91. Gross RE. Surgical relief for tracheal obstruction from a vas-cular ring. N Engl J Med. 1945;233:586-590. 92. Sade RM, Rosenthal |
Surgery_Schwartz_5304 | Surgery_Schwartz | subaortic stenosis. J Thorac Cardiovasc Surg. 1990;100(5):672-681. 91. Gross RE. Surgical relief for tracheal obstruction from a vas-cular ring. N Engl J Med. 1945;233:586-590. 92. Sade RM, Rosenthal A, Fellows K, Castaneda AR. Pulmonary artery sling. J Thorac Cardiovasc Surg. 1975;69(3):333-346. 93. Clarke NS, Murthy R, Hernandez J, Megison S, Guleserian KJ. Aortoesophageal fistula in a child with undiagnosed vascular ring: life-threatening or lethal? Ann Thorac Surg. 2016;102(4):e325-e327. 94. Laborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgi-cal technique for interruption of patient ductus arteriosus in infants and children. J Thorac Cardiovasc Surg. 1993;105(2): 278-280. 95. Burke RP, Wernovsky G, van der Velde M, Hansen D, Castaneda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg. 1995;109(3):499-507; discussion 508. 96. Kogon BE, Forbess JM, Wulkan ML, Kirshbom PM, | Surgery_Schwartz. subaortic stenosis. J Thorac Cardiovasc Surg. 1990;100(5):672-681. 91. Gross RE. Surgical relief for tracheal obstruction from a vas-cular ring. N Engl J Med. 1945;233:586-590. 92. Sade RM, Rosenthal A, Fellows K, Castaneda AR. Pulmonary artery sling. J Thorac Cardiovasc Surg. 1975;69(3):333-346. 93. Clarke NS, Murthy R, Hernandez J, Megison S, Guleserian KJ. Aortoesophageal fistula in a child with undiagnosed vascular ring: life-threatening or lethal? Ann Thorac Surg. 2016;102(4):e325-e327. 94. Laborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgi-cal technique for interruption of patient ductus arteriosus in infants and children. J Thorac Cardiovasc Surg. 1993;105(2): 278-280. 95. Burke RP, Wernovsky G, van der Velde M, Hansen D, Castaneda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg. 1995;109(3):499-507; discussion 508. 96. Kogon BE, Forbess JM, Wulkan ML, Kirshbom PM, |
Surgery_Schwartz_5305 | Surgery_Schwartz | D, Castaneda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg. 1995;109(3):499-507; discussion 508. 96. Kogon BE, Forbess JM, Wulkan ML, Kirshbom PM, Kanter KR. Video-assisted thoracoscopic surgery: is it a superior technique for the division of vascular rings in children? Congenit Heart Dis. 2007;2(2):130-133. 97. Berlin Heart. EXCOR pediatric update. Available at: http://www.berlinheart.de/UserFiles/ClinicalUpdateEXCORPedi-atricMai2016.pdf. Accessed May 19, 2018. 98. Trusler GA, Williams WG. Long-term results of shunt procedures for tricuspid atresia. Ann Thorac Surg. 1980; 29(4):312-316. 99. Dick M, Gyler DC, Nadas AS. Tricuspid atresia: clinical course in 101 patients. Am J Cardiol. 1975;36(3):327-337. 100. Glenn WWL, Patino JF. Circulatory by-pass of the right heart. Preliminary observations on the direct delivery of vena caval blood into the pulmonary arterial circulation. Azygous vein-pulmonary artery shunt. Yale J Biol Med. | Surgery_Schwartz. D, Castaneda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg. 1995;109(3):499-507; discussion 508. 96. Kogon BE, Forbess JM, Wulkan ML, Kirshbom PM, Kanter KR. Video-assisted thoracoscopic surgery: is it a superior technique for the division of vascular rings in children? Congenit Heart Dis. 2007;2(2):130-133. 97. Berlin Heart. EXCOR pediatric update. Available at: http://www.berlinheart.de/UserFiles/ClinicalUpdateEXCORPedi-atricMai2016.pdf. Accessed May 19, 2018. 98. Trusler GA, Williams WG. Long-term results of shunt procedures for tricuspid atresia. Ann Thorac Surg. 1980; 29(4):312-316. 99. Dick M, Gyler DC, Nadas AS. Tricuspid atresia: clinical course in 101 patients. Am J Cardiol. 1975;36(3):327-337. 100. Glenn WWL, Patino JF. Circulatory by-pass of the right heart. Preliminary observations on the direct delivery of vena caval blood into the pulmonary arterial circulation. Azygous vein-pulmonary artery shunt. Yale J Biol Med. |
Surgery_Schwartz_5306 | Surgery_Schwartz | by-pass of the right heart. Preliminary observations on the direct delivery of vena caval blood into the pulmonary arterial circulation. Azygous vein-pulmonary artery shunt. Yale J Biol Med. 1954;27(3): 147-151. 101. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971;26(3):240-248. 102. deLeval MR, Kilner P, Gerwillig M, Bull C. Total cavopulmo-nary connection: a logical alternative to atriopulmonary con-nection for complex Fontan operations. J Thorac Cardiovasc Surg. 1988;96(5):682-695. 103. Laks H, Haas GS, Pearl JM, et al. The use of an adjust-able interatrial communication in patients undergoing the Fontan and definitive heart procedures. Ann Thorac Surg. 1991;52(5):1084-1094. 105. Haas GS, Hess H, Black M, Onnasch J, Mohr FW, van Son JA. Extracardiac conduit Fontan procedure: early and intermedi-ate results. Eur J Cardiothorac Surg. 2000;17(6):648-654. 106. Tokunaga S, Kado H, Imoto Y, et al. Total cavopulmonary connection with an extracardiac conduit: | Surgery_Schwartz. by-pass of the right heart. Preliminary observations on the direct delivery of vena caval blood into the pulmonary arterial circulation. Azygous vein-pulmonary artery shunt. Yale J Biol Med. 1954;27(3): 147-151. 101. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971;26(3):240-248. 102. deLeval MR, Kilner P, Gerwillig M, Bull C. Total cavopulmo-nary connection: a logical alternative to atriopulmonary con-nection for complex Fontan operations. J Thorac Cardiovasc Surg. 1988;96(5):682-695. 103. Laks H, Haas GS, Pearl JM, et al. The use of an adjust-able interatrial communication in patients undergoing the Fontan and definitive heart procedures. Ann Thorac Surg. 1991;52(5):1084-1094. 105. Haas GS, Hess H, Black M, Onnasch J, Mohr FW, van Son JA. Extracardiac conduit Fontan procedure: early and intermedi-ate results. Eur J Cardiothorac Surg. 2000;17(6):648-654. 106. Tokunaga S, Kado H, Imoto Y, et al. Total cavopulmonary connection with an extracardiac conduit: |
Surgery_Schwartz_5307 | Surgery_Schwartz | Fontan procedure: early and intermedi-ate results. Eur J Cardiothorac Surg. 2000;17(6):648-654. 106. Tokunaga S, Kado H, Imoto Y, et al. Total cavopulmonary connection with an extracardiac conduit: experience with 100 patients. Ann Thorac Surg. 2002;73(1):76-80. 107. Karamlou T, Ashburn DA, Caldarone CA, Blackstone EH. Matching procedure to morphology improves outcome in neonates with tricuspid atresia. J Thorac Cardiovasc Surg. 2005;130:1503-1510. 108. Bardo DME, Frankel DG, Applegate KE, Murphy DJ, Saneto RP. Hypoplastic left heart syndrome. Radiographics. 2001;21(3): 706-717. 109. Norwood WI Jr. Hypoplastic left heart syndrome. Ann Thorac Surg. 1991;52(3):688-695. 110. Bronshtein M, Zimmer EZ. Early sonographic diagnosis of fetal small left heart ventricle with a normal proximal outlet tract: a medical dilemma. Prenat Diagn. 1997;17(3):249-253.Brunicardi_Ch20_p0751-p0800.indd 79722/02/19 2:57 PM 798SPECIFIC CONSIDERATIONSPART II 111. Norwood WI, Lang P, Hansen DD. Physiologic | Surgery_Schwartz. Fontan procedure: early and intermedi-ate results. Eur J Cardiothorac Surg. 2000;17(6):648-654. 106. Tokunaga S, Kado H, Imoto Y, et al. Total cavopulmonary connection with an extracardiac conduit: experience with 100 patients. Ann Thorac Surg. 2002;73(1):76-80. 107. Karamlou T, Ashburn DA, Caldarone CA, Blackstone EH. Matching procedure to morphology improves outcome in neonates with tricuspid atresia. J Thorac Cardiovasc Surg. 2005;130:1503-1510. 108. Bardo DME, Frankel DG, Applegate KE, Murphy DJ, Saneto RP. Hypoplastic left heart syndrome. Radiographics. 2001;21(3): 706-717. 109. Norwood WI Jr. Hypoplastic left heart syndrome. Ann Thorac Surg. 1991;52(3):688-695. 110. Bronshtein M, Zimmer EZ. Early sonographic diagnosis of fetal small left heart ventricle with a normal proximal outlet tract: a medical dilemma. Prenat Diagn. 1997;17(3):249-253.Brunicardi_Ch20_p0751-p0800.indd 79722/02/19 2:57 PM 798SPECIFIC CONSIDERATIONSPART II 111. Norwood WI, Lang P, Hansen DD. Physiologic |
Surgery_Schwartz_5308 | Surgery_Schwartz | tract: a medical dilemma. Prenat Diagn. 1997;17(3):249-253.Brunicardi_Ch20_p0751-p0800.indd 79722/02/19 2:57 PM 798SPECIFIC CONSIDERATIONSPART II 111. Norwood WI, Lang P, Hansen DD. Physiologic repair of aor-tic atresia-hypoplastic left heart syndrome. N Engl J Med. 1983;308(1):23-26. 112. Tweddell JS, Hoffman GM, Ghanayem NS, et al. Ventilatory control of pulmonary vascular resistance is not necessary to achieve a balanced circulation in the postoperative Norwood patient. Circulation. 1999;100(18 suppl):I-671. 113. Sano S, Ishino K, Kawada M. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg. 2003;126(2):504-509; discussion 1609-1610. 114. Tchervenkov CI. Two-ventricle repair for hypoplastic left heart syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:83-93. 115. Ohye RG, Sleeper la, Mahony L, et al. Comparison of shunt types in the Norwood procedure for single ventricle lesions. N | Surgery_Schwartz. tract: a medical dilemma. Prenat Diagn. 1997;17(3):249-253.Brunicardi_Ch20_p0751-p0800.indd 79722/02/19 2:57 PM 798SPECIFIC CONSIDERATIONSPART II 111. Norwood WI, Lang P, Hansen DD. Physiologic repair of aor-tic atresia-hypoplastic left heart syndrome. N Engl J Med. 1983;308(1):23-26. 112. Tweddell JS, Hoffman GM, Ghanayem NS, et al. Ventilatory control of pulmonary vascular resistance is not necessary to achieve a balanced circulation in the postoperative Norwood patient. Circulation. 1999;100(18 suppl):I-671. 113. Sano S, Ishino K, Kawada M. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg. 2003;126(2):504-509; discussion 1609-1610. 114. Tchervenkov CI. Two-ventricle repair for hypoplastic left heart syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:83-93. 115. Ohye RG, Sleeper la, Mahony L, et al. Comparison of shunt types in the Norwood procedure for single ventricle lesions. N |
Surgery_Schwartz_5309 | Surgery_Schwartz | Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:83-93. 115. Ohye RG, Sleeper la, Mahony L, et al. Comparison of shunt types in the Norwood procedure for single ventricle lesions. N Engl J Med. 2010;362:1980-1992. 116. Newburger JW, Sleeper LA, Frommelt PC, et al; Pediatric Heart Network Investigators. Transplantation-free sur-vival and interventions at 3 years in the single ventricle reconstruction trial. Circulation. 2014;129:2013-2020. This article discusses the long-term outcomes of the Norwood procedure for patients with the Sano or BT shunt. This is a landmark article in the field. 117. Pasquali SK, Ohye RG, Lu M, et al; Pediatric Heart Network Investigators. Variation in perioperative care across centers for infants undergoing the Norwood procedure. J Thorac Cardio-vasc Surg. 2012;144:915-144. 118. Ohye RG, Schranz D, D’Udekem Y. Current therapy for hypo-plastic left heart syndrome and related single ventricle lesions. Circulation. 2016 | Surgery_Schwartz. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:83-93. 115. Ohye RG, Sleeper la, Mahony L, et al. Comparison of shunt types in the Norwood procedure for single ventricle lesions. N Engl J Med. 2010;362:1980-1992. 116. Newburger JW, Sleeper LA, Frommelt PC, et al; Pediatric Heart Network Investigators. Transplantation-free sur-vival and interventions at 3 years in the single ventricle reconstruction trial. Circulation. 2014;129:2013-2020. This article discusses the long-term outcomes of the Norwood procedure for patients with the Sano or BT shunt. This is a landmark article in the field. 117. Pasquali SK, Ohye RG, Lu M, et al; Pediatric Heart Network Investigators. Variation in perioperative care across centers for infants undergoing the Norwood procedure. J Thorac Cardio-vasc Surg. 2012;144:915-144. 118. Ohye RG, Schranz D, D’Udekem Y. Current therapy for hypo-plastic left heart syndrome and related single ventricle lesions. Circulation. 2016 |
Surgery_Schwartz_5310 | Surgery_Schwartz | J Thorac Cardio-vasc Surg. 2012;144:915-144. 118. Ohye RG, Schranz D, D’Udekem Y. Current therapy for hypo-plastic left heart syndrome and related single ventricle lesions. Circulation. 2016 Oct;134(17):1265-1279. 119. Murthy R, Sebastian VA, Huang R, Guleserian KJ, Forbess JM. Selective use of the Blalock–Taussig shunt and right ventricle-to-pulmonary artery conduit dur-ing the Norwood procedure. World J Pediatr Congenit Heart Surg. 2016;7(3):329-333. This article elucidates the extensive debate that determines the source of pulmonary blood flow after the Norwood operation. The selective use of mBTS can be beneficial. 120. Wilder TJ, McCrindle BW, Phillips AB, et al. Survival and right ventricular performance for matched children after stage-1 Norwood: modified Blalock–Taussig shunt versus right-ventricle-to-pulmonary-artery conduit. J Thorac Cardio-vasc Surg. 2015;150(6):1440-1450; discussion 1450-1452. 121. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial | Surgery_Schwartz. J Thorac Cardio-vasc Surg. 2012;144:915-144. 118. Ohye RG, Schranz D, D’Udekem Y. Current therapy for hypo-plastic left heart syndrome and related single ventricle lesions. Circulation. 2016 Oct;134(17):1265-1279. 119. Murthy R, Sebastian VA, Huang R, Guleserian KJ, Forbess JM. Selective use of the Blalock–Taussig shunt and right ventricle-to-pulmonary artery conduit dur-ing the Norwood procedure. World J Pediatr Congenit Heart Surg. 2016;7(3):329-333. This article elucidates the extensive debate that determines the source of pulmonary blood flow after the Norwood operation. The selective use of mBTS can be beneficial. 120. Wilder TJ, McCrindle BW, Phillips AB, et al. Survival and right ventricular performance for matched children after stage-1 Norwood: modified Blalock–Taussig shunt versus right-ventricle-to-pulmonary-artery conduit. J Thorac Cardio-vasc Surg. 2015;150(6):1440-1450; discussion 1450-1452. 121. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial |
Surgery_Schwartz_5311 | Surgery_Schwartz | right-ventricle-to-pulmonary-artery conduit. J Thorac Cardio-vasc Surg. 2015;150(6):1440-1450; discussion 1450-1452. 121. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial duct and banding of the pulmonary arteries: basis for combined Norwood Stage I and II repair in hypoplastic left heart. Circulation. 2002;105:1099-1103. 122. Caldarone CA, Benson L, Holtby H, Li J, Redington AN, VanArsdell GS. Initial experience with hybrid palliation for neonates with single ventricle physiology. Ann Thorac Surg. 2007;84:1294-1300. 123. Baba K, Honjo O, Chaturvedi R, et al. “Reverse Blalock–Taussig shunt”: application in single ventricle hybrid pallia-tion. J Thorac Cardiovasc Surg. 2013;146(2):352-357. 124. Guleserian KJ, Barker GM, Sharma MS, et al. Bilateral pul-monary artery banding for resuscitation in high-risk, single-ventricle neonates and infants: a single-center experience. J Thorac Cardiovasc Surg. 2013;145(1):206-213; discussion 213-214. 125. Myers PO, Baird CW, | Surgery_Schwartz. right-ventricle-to-pulmonary-artery conduit. J Thorac Cardio-vasc Surg. 2015;150(6):1440-1450; discussion 1450-1452. 121. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial duct and banding of the pulmonary arteries: basis for combined Norwood Stage I and II repair in hypoplastic left heart. Circulation. 2002;105:1099-1103. 122. Caldarone CA, Benson L, Holtby H, Li J, Redington AN, VanArsdell GS. Initial experience with hybrid palliation for neonates with single ventricle physiology. Ann Thorac Surg. 2007;84:1294-1300. 123. Baba K, Honjo O, Chaturvedi R, et al. “Reverse Blalock–Taussig shunt”: application in single ventricle hybrid pallia-tion. J Thorac Cardiovasc Surg. 2013;146(2):352-357. 124. Guleserian KJ, Barker GM, Sharma MS, et al. Bilateral pul-monary artery banding for resuscitation in high-risk, single-ventricle neonates and infants: a single-center experience. J Thorac Cardiovasc Surg. 2013;145(1):206-213; discussion 213-214. 125. Myers PO, Baird CW, |
Surgery_Schwartz_5312 | Surgery_Schwartz | banding for resuscitation in high-risk, single-ventricle neonates and infants: a single-center experience. J Thorac Cardiovasc Surg. 2013;145(1):206-213; discussion 213-214. 125. Myers PO, Baird CW, Del Nido PJ, et al. Neonatal mitral valve repair in biventricular repair, single ventricle palliation, and secondary left ventricular recruitment: indications, tech-niques, and mid-term outcomes. Front Surg. 2015;2:59. 126. Bailey LL, Gundry SR, Razzouk AJ, et al. Bless the babies: 115 late survivors of heart transplantation during the first year of life. The Loma Linda University Pediatric Heart Transplant Group. J Thorac Cardiovas Surg. 1993;105:805-814. 127. Gaynor JW, Mahle WT, Cohen MI, et al. Risk factors for mor-tality after the Norwood procedure. Eur J Cardiothorac Surg. 2002;22:82-89. 128. Bove EL. Ebstein’s anomaly in the neonate. Rev Port Cardiol. 2001;20(9):865-873. 129. Celermajer DS, Cullen S, Sullivan ID, et al. Outcome in neonates with Ebstein’s anomaly. J Am Coll Cardiol. | Surgery_Schwartz. banding for resuscitation in high-risk, single-ventricle neonates and infants: a single-center experience. J Thorac Cardiovasc Surg. 2013;145(1):206-213; discussion 213-214. 125. Myers PO, Baird CW, Del Nido PJ, et al. Neonatal mitral valve repair in biventricular repair, single ventricle palliation, and secondary left ventricular recruitment: indications, tech-niques, and mid-term outcomes. Front Surg. 2015;2:59. 126. Bailey LL, Gundry SR, Razzouk AJ, et al. Bless the babies: 115 late survivors of heart transplantation during the first year of life. The Loma Linda University Pediatric Heart Transplant Group. J Thorac Cardiovas Surg. 1993;105:805-814. 127. Gaynor JW, Mahle WT, Cohen MI, et al. Risk factors for mor-tality after the Norwood procedure. Eur J Cardiothorac Surg. 2002;22:82-89. 128. Bove EL. Ebstein’s anomaly in the neonate. Rev Port Cardiol. 2001;20(9):865-873. 129. Celermajer DS, Cullen S, Sullivan ID, et al. Outcome in neonates with Ebstein’s anomaly. J Am Coll Cardiol. |
Surgery_Schwartz_5313 | Surgery_Schwartz | EL. Ebstein’s anomaly in the neonate. Rev Port Cardiol. 2001;20(9):865-873. 129. Celermajer DS, Cullen S, Sullivan ID, et al. Outcome in neonates with Ebstein’s anomaly. J Am Coll Cardiol. 1992;19:1041-1046. 130. Starnes VA, Pitlick PT, Bernstein D, Griffin ML, Choy M, Shumway NE. Ebstein’s anomaly appearing in the neonate. J Thorac Cardiovasc Surg. 1991;101(6):1082-1087. 131. Danielson GK, Driscoll DJ, Mair DD, Warnes CA, Oliver WC Jr. Operative treatment of Ebstein’s anomaly. J Thorac Cardiovasc Surg. 1992;104:1195-1202. 132. Knott-Craig CJ, Overholt ED, Ward KE, Razook JD. Neo-natal repair of Ebstein’s anomaly: indications, surgical technique, and medium-term follow-up. Ann Thorac Surg. 2000;69(5):1505-1510. 133. Yetman AT, Freedom RM, McCrindle BW. Outcome in cyanotic neonates with Ebstein’s anomaly. Am J Cardiol. 1998;81(6):749-754. 134. Billingsly AM, Laks H, Boyce SW, George B, Santulli T, Williams RG. Definitive repair in patients with pulmonary atresia and intact ventricular | Surgery_Schwartz. EL. Ebstein’s anomaly in the neonate. Rev Port Cardiol. 2001;20(9):865-873. 129. Celermajer DS, Cullen S, Sullivan ID, et al. Outcome in neonates with Ebstein’s anomaly. J Am Coll Cardiol. 1992;19:1041-1046. 130. Starnes VA, Pitlick PT, Bernstein D, Griffin ML, Choy M, Shumway NE. Ebstein’s anomaly appearing in the neonate. J Thorac Cardiovasc Surg. 1991;101(6):1082-1087. 131. Danielson GK, Driscoll DJ, Mair DD, Warnes CA, Oliver WC Jr. Operative treatment of Ebstein’s anomaly. J Thorac Cardiovasc Surg. 1992;104:1195-1202. 132. Knott-Craig CJ, Overholt ED, Ward KE, Razook JD. Neo-natal repair of Ebstein’s anomaly: indications, surgical technique, and medium-term follow-up. Ann Thorac Surg. 2000;69(5):1505-1510. 133. Yetman AT, Freedom RM, McCrindle BW. Outcome in cyanotic neonates with Ebstein’s anomaly. Am J Cardiol. 1998;81(6):749-754. 134. Billingsly AM, Laks H, Boyce SW, George B, Santulli T, Williams RG. Definitive repair in patients with pulmonary atresia and intact ventricular |
Surgery_Schwartz_5314 | Surgery_Schwartz | anomaly. Am J Cardiol. 1998;81(6):749-754. 134. Billingsly AM, Laks H, Boyce SW, George B, Santulli T, Williams RG. Definitive repair in patients with pulmonary atresia and intact ventricular septum. J Thorac Cardiovasc Surg. 1989;97(5):746-754. 135. Stellin G, Vida VL, Milanesi O, et al. Surgical treatment of complex cardiac anomalies: the “one and one half ventricle repair.” Eur J Cardiothorac Surg. 2002;22(3):435-437. 136. Chowdhury UK, Airan B, Sharma R, et al. One and a half ventricle repair with pulsatile Glenn: results and guidelines for patient selection. Ann Thorac Surg. 2001;71(6):2000-2002. 137. Knott-Craig CJ, Kumar TK, Arevalo AR, Joshi VM. Surgical management of symptomatic neonates with Ebstein’s anomaly: choice of operation. Cardiol Young. 2015;25(6):1119-1123. 138. Van Praagh R, Van Praagh S, Vlad P, Keith JC. Anatomic sub-types of congenital dextrocardia: diagnostic and embryologic implications. Am J Cardiol. 1964;13:510-531. 139. Van Praagh R, Van Praagh S. Isolated | Surgery_Schwartz. anomaly. Am J Cardiol. 1998;81(6):749-754. 134. Billingsly AM, Laks H, Boyce SW, George B, Santulli T, Williams RG. Definitive repair in patients with pulmonary atresia and intact ventricular septum. J Thorac Cardiovasc Surg. 1989;97(5):746-754. 135. Stellin G, Vida VL, Milanesi O, et al. Surgical treatment of complex cardiac anomalies: the “one and one half ventricle repair.” Eur J Cardiothorac Surg. 2002;22(3):435-437. 136. Chowdhury UK, Airan B, Sharma R, et al. One and a half ventricle repair with pulsatile Glenn: results and guidelines for patient selection. Ann Thorac Surg. 2001;71(6):2000-2002. 137. Knott-Craig CJ, Kumar TK, Arevalo AR, Joshi VM. Surgical management of symptomatic neonates with Ebstein’s anomaly: choice of operation. Cardiol Young. 2015;25(6):1119-1123. 138. Van Praagh R, Van Praagh S, Vlad P, Keith JC. Anatomic sub-types of congenital dextrocardia: diagnostic and embryologic implications. Am J Cardiol. 1964;13:510-531. 139. Van Praagh R, Van Praagh S. Isolated |
Surgery_Schwartz_5315 | Surgery_Schwartz | R, Van Praagh S, Vlad P, Keith JC. Anatomic sub-types of congenital dextrocardia: diagnostic and embryologic implications. Am J Cardiol. 1964;13:510-531. 139. Van Praagh R, Van Praagh S. Isolated ventricular inversion: a consideration of the morphogenesis, definition, and diagnosis of nontransposed and transposed great arteries. Am J Cardiol. 1966;17:395-406. 140. Blalock A, Hanlon CR. The surgical treatment of complete transposition of the aorta and the pulmonary artery. Surg Gynecol Obstet. 1950;90(1):1-15. 141. Senning A. Surgical correction of transposition of the great vessel. Surgery. 1959;45(6):966-980. 142. Mustard WT, Chute AL, Keith JD, Sirek A, Rowe RD, Vlad P. A surgical approach to transposition of the great vessels with extracorporeal circuit. Surgery. 1954;36:31-59. 143. Jatene AD, Fontes VF, Paulista PP, et al. Successful anatomic correction of transposition of the great vessels: a preliminary report. Arq Bras Cardiol. 1975;28(4):461-464. 144. Rastelli GC. A new | Surgery_Schwartz. R, Van Praagh S, Vlad P, Keith JC. Anatomic sub-types of congenital dextrocardia: diagnostic and embryologic implications. Am J Cardiol. 1964;13:510-531. 139. Van Praagh R, Van Praagh S. Isolated ventricular inversion: a consideration of the morphogenesis, definition, and diagnosis of nontransposed and transposed great arteries. Am J Cardiol. 1966;17:395-406. 140. Blalock A, Hanlon CR. The surgical treatment of complete transposition of the aorta and the pulmonary artery. Surg Gynecol Obstet. 1950;90(1):1-15. 141. Senning A. Surgical correction of transposition of the great vessel. Surgery. 1959;45(6):966-980. 142. Mustard WT, Chute AL, Keith JD, Sirek A, Rowe RD, Vlad P. A surgical approach to transposition of the great vessels with extracorporeal circuit. Surgery. 1954;36:31-59. 143. Jatene AD, Fontes VF, Paulista PP, et al. Successful anatomic correction of transposition of the great vessels: a preliminary report. Arq Bras Cardiol. 1975;28(4):461-464. 144. Rastelli GC. A new |
Surgery_Schwartz_5316 | Surgery_Schwartz | AD, Fontes VF, Paulista PP, et al. Successful anatomic correction of transposition of the great vessels: a preliminary report. Arq Bras Cardiol. 1975;28(4):461-464. 144. Rastelli GC. A new approach to the “anatomic” repair of transposition of the great arteries. Mayo Clin Proc. 1969; 44(1):1-12. 145. Culbert EL, Ashburn DA, Cullen-Dean G, et al. Quality of life after repair of transposition of the great arteries. Circulation. 2003;108:857-862. 146. Dearani JA, Danielson GK, Puga FJ, Mair DD, Schleck CD. Late results of the Rastelli operation for transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:3-15. 147. Freedom RM, Yoo SJ. Double-outlet right ventricle: pathol-ogy and angiocardiography. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2000;3:3-19. 148. Lev M, Bharati S, Meng CCL, et al. A concept of double outlet right ventricle. J Thorac Cardiovasc Surg. 1972; 64(2):271-281.Brunicardi_Ch20_p0751-p0800.indd 79822/02/19 2:57 PM | Surgery_Schwartz. AD, Fontes VF, Paulista PP, et al. Successful anatomic correction of transposition of the great vessels: a preliminary report. Arq Bras Cardiol. 1975;28(4):461-464. 144. Rastelli GC. A new approach to the “anatomic” repair of transposition of the great arteries. Mayo Clin Proc. 1969; 44(1):1-12. 145. Culbert EL, Ashburn DA, Cullen-Dean G, et al. Quality of life after repair of transposition of the great arteries. Circulation. 2003;108:857-862. 146. Dearani JA, Danielson GK, Puga FJ, Mair DD, Schleck CD. Late results of the Rastelli operation for transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:3-15. 147. Freedom RM, Yoo SJ. Double-outlet right ventricle: pathol-ogy and angiocardiography. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2000;3:3-19. 148. Lev M, Bharati S, Meng CCL, et al. A concept of double outlet right ventricle. J Thorac Cardiovasc Surg. 1972; 64(2):271-281.Brunicardi_Ch20_p0751-p0800.indd 79822/02/19 2:57 PM |
Surgery_Schwartz_5317 | Surgery_Schwartz | 2000;3:3-19. 148. Lev M, Bharati S, Meng CCL, et al. A concept of double outlet right ventricle. J Thorac Cardiovasc Surg. 1972; 64(2):271-281.Brunicardi_Ch20_p0751-p0800.indd 79822/02/19 2:57 PM 799CONGENITAL HEART DISEASECHAPTER 20 149. Taussig HB, Bing RJ. Complete transposition of the aorta and a levoposition of the pulmonary artery. Am Heart J. 1949;37(4):551-559. 150. Bradley TJ, Karamlou T, Kulik A, et al. Determinants of repair type, reintervention, and mortality in 393 children with double-outlet right ventricle. J Thorac Cardiovasc Surg. 2007;134(4):967-973.e6. 151. Belli E, Serraf A, Lacour-Gayet F, et al. Double-outlet right ventricle with non-committed ventricular septal defect. Eur J Cardiothorac Surg. 1999;15(6):747-752. 152. Kawashima Y, Matsuda H, Yagihara T, et al. Intraventricular repair for Taussig–Bing anomaly. J Thorac Cardiovasc Surg. 1993;105:591-596. 153. Rastelli GC, McGoon DC, Wallace RB. Anatomic correction of transposition of the great arteries with | Surgery_Schwartz. 2000;3:3-19. 148. Lev M, Bharati S, Meng CCL, et al. A concept of double outlet right ventricle. J Thorac Cardiovasc Surg. 1972; 64(2):271-281.Brunicardi_Ch20_p0751-p0800.indd 79822/02/19 2:57 PM 799CONGENITAL HEART DISEASECHAPTER 20 149. Taussig HB, Bing RJ. Complete transposition of the aorta and a levoposition of the pulmonary artery. Am Heart J. 1949;37(4):551-559. 150. Bradley TJ, Karamlou T, Kulik A, et al. Determinants of repair type, reintervention, and mortality in 393 children with double-outlet right ventricle. J Thorac Cardiovasc Surg. 2007;134(4):967-973.e6. 151. Belli E, Serraf A, Lacour-Gayet F, et al. Double-outlet right ventricle with non-committed ventricular septal defect. Eur J Cardiothorac Surg. 1999;15(6):747-752. 152. Kawashima Y, Matsuda H, Yagihara T, et al. Intraventricular repair for Taussig–Bing anomaly. J Thorac Cardiovasc Surg. 1993;105:591-596. 153. Rastelli GC, McGoon DC, Wallace RB. Anatomic correction of transposition of the great arteries with |
Surgery_Schwartz_5318 | Surgery_Schwartz | Intraventricular repair for Taussig–Bing anomaly. J Thorac Cardiovasc Surg. 1993;105:591-596. 153. Rastelli GC, McGoon DC, Wallace RB. Anatomic correction of transposition of the great arteries with ventricular septal defect and subpulmonic stenosis. J Thorac Cardiovasc Surg. 1969;58(4):545-552. 154. Yasui H, Kado H, Nakano E, et al. Primary repair of inter-rupted aortic arch with severe stenosis in neonates. J Thorac Cardiovasc Surg. 1987;93:539-545. 155. Brown JW, Ruzmetov M, Okada Y, Vijay P, Turrentine MW. Surgical results in patients with double outlet right ventricle: a 20-year experience. Ann Thorac Surg. 2001;72(5):1630-1635. 156. Fallot A. Contribution a l’anatomie pathologique de la mal-adie bleue (cyanose cardiaque) (French). Marseille Med. 1888;25:77-403. 157. Van Praagh R, Van Praagh S, Nebesar RA, et al. Tetralogy of Fallot: underdevelopment of the pulmonary infundibulum and its sequelae. Am J Cardiol. 1970;26:25-53. 158. Need LR, Powell AJ, del Nido P, Geva T. Coronary | Surgery_Schwartz. Intraventricular repair for Taussig–Bing anomaly. J Thorac Cardiovasc Surg. 1993;105:591-596. 153. Rastelli GC, McGoon DC, Wallace RB. Anatomic correction of transposition of the great arteries with ventricular septal defect and subpulmonic stenosis. J Thorac Cardiovasc Surg. 1969;58(4):545-552. 154. Yasui H, Kado H, Nakano E, et al. Primary repair of inter-rupted aortic arch with severe stenosis in neonates. J Thorac Cardiovasc Surg. 1987;93:539-545. 155. Brown JW, Ruzmetov M, Okada Y, Vijay P, Turrentine MW. Surgical results in patients with double outlet right ventricle: a 20-year experience. Ann Thorac Surg. 2001;72(5):1630-1635. 156. Fallot A. Contribution a l’anatomie pathologique de la mal-adie bleue (cyanose cardiaque) (French). Marseille Med. 1888;25:77-403. 157. Van Praagh R, Van Praagh S, Nebesar RA, et al. Tetralogy of Fallot: underdevelopment of the pulmonary infundibulum and its sequelae. Am J Cardiol. 1970;26:25-53. 158. Need LR, Powell AJ, del Nido P, Geva T. Coronary |
Surgery_Schwartz_5319 | Surgery_Schwartz | Praagh S, Nebesar RA, et al. Tetralogy of Fallot: underdevelopment of the pulmonary infundibulum and its sequelae. Am J Cardiol. 1970;26:25-53. 158. Need LR, Powell AJ, del Nido P, Geva T. Coronary echocar-diography in tetralogy of Fallot: diagnostic accuracy, resource utilization, and surgical implications over 13 years. J Am Coll Cardiol. 2000;36(4):1371-1377. 159. Mahle WT, McBride MG, Paridon SM. Exercise performance in tetralogy of Fallot: the impact of primary complete repair in infancy. Pediatr Cardiol. 2002;23(2):224-229. 160. Deanfield JE. Adult congenital heart disease with special refernce to the data on long-term follow-up of patients sur-viving to adulthood with or without surgical correction. Eur Heart J. 1992;13(suppl H):111-116. 161. Alexiou C, Chen Q, Galogavrou M, et al. Repair of tetral-ogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg. 2002;22(2):174-183. 162. Al Habib HF, Jacobs JP, Mavroudis C, et al. Contemporary | Surgery_Schwartz. Praagh S, Nebesar RA, et al. Tetralogy of Fallot: underdevelopment of the pulmonary infundibulum and its sequelae. Am J Cardiol. 1970;26:25-53. 158. Need LR, Powell AJ, del Nido P, Geva T. Coronary echocar-diography in tetralogy of Fallot: diagnostic accuracy, resource utilization, and surgical implications over 13 years. J Am Coll Cardiol. 2000;36(4):1371-1377. 159. Mahle WT, McBride MG, Paridon SM. Exercise performance in tetralogy of Fallot: the impact of primary complete repair in infancy. Pediatr Cardiol. 2002;23(2):224-229. 160. Deanfield JE. Adult congenital heart disease with special refernce to the data on long-term follow-up of patients sur-viving to adulthood with or without surgical correction. Eur Heart J. 1992;13(suppl H):111-116. 161. Alexiou C, Chen Q, Galogavrou M, et al. Repair of tetral-ogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg. 2002;22(2):174-183. 162. Al Habib HF, Jacobs JP, Mavroudis C, et al. Contemporary |
Surgery_Schwartz_5320 | Surgery_Schwartz | Repair of tetral-ogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg. 2002;22(2):174-183. 162. Al Habib HF, Jacobs JP, Mavroudis C, et al. Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2010;90(3):813-819; discussion 819-820. 163. Karamlou T, McCrindle BW, Williams WG. Surgery insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. Nature Cardiovasc Med. 2006;3:611-622. 164. Gatzoulis MA, Till JA, Somerville J, et al. Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation. 1995;92:231-237. 165. Karamlou T, Silber I, Lao R, et al. Outcomes after late reop-eration in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg. | Surgery_Schwartz. Repair of tetral-ogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg. 2002;22(2):174-183. 162. Al Habib HF, Jacobs JP, Mavroudis C, et al. Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2010;90(3):813-819; discussion 819-820. 163. Karamlou T, McCrindle BW, Williams WG. Surgery insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. Nature Cardiovasc Med. 2006;3:611-622. 164. Gatzoulis MA, Till JA, Somerville J, et al. Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation. 1995;92:231-237. 165. Karamlou T, Silber I, Lao R, et al. Outcomes after late reop-eration in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg. |
Surgery_Schwartz_5321 | Surgery_Schwartz | T, Silber I, Lao R, et al. Outcomes after late reop-eration in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg. 2006;81:1786-1793. 166. Geva T. Indications and timing of pulmonary valve replace-ment after tetralogy of Fallot repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006:11-22. Review. 167. Khanna AD, Hill KD, Pasquali SK, et al. Benchmark out-comes for pulmonary valve replacement using the Soci-ety of Thoracic Surgeons databases. Ann Thorac Surg. 2015;100(1):138-145; discussion 145-6. doi: 10.1016/j.atho-racsur.2015.03.025. With the increasing number of adults with congenital heart disease, this article describes the benchmark outcomes for one of the most commonly per-formed operations in this population. 168. Steinberg ZL, Jones TK, Verrier E, Stout KK, Krieger EV, Karamlou T. Early outcomes in patients undergoing trans-catheter versus surgical pulmonary valve replacement. Heart. 2017 Mar 28. doi: | Surgery_Schwartz. T, Silber I, Lao R, et al. Outcomes after late reop-eration in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg. 2006;81:1786-1793. 166. Geva T. Indications and timing of pulmonary valve replace-ment after tetralogy of Fallot repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006:11-22. Review. 167. Khanna AD, Hill KD, Pasquali SK, et al. Benchmark out-comes for pulmonary valve replacement using the Soci-ety of Thoracic Surgeons databases. Ann Thorac Surg. 2015;100(1):138-145; discussion 145-6. doi: 10.1016/j.atho-racsur.2015.03.025. With the increasing number of adults with congenital heart disease, this article describes the benchmark outcomes for one of the most commonly per-formed operations in this population. 168. Steinberg ZL, Jones TK, Verrier E, Stout KK, Krieger EV, Karamlou T. Early outcomes in patients undergoing trans-catheter versus surgical pulmonary valve replacement. Heart. 2017 Mar 28. doi: |
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Surgery_Schwartz_5323 | Surgery_Schwartz | Surg. 2008;136(5):1223-1228. 172. Seddio F, Reddy VM, McElhinney DB, Tworetzky W, Silverman NH, Hanley FL. Multiple ventricular septal defects: how and when should they be repaired? J Thorac Cardiovasc Surg. 1999;117(1):134-139. 173. Tsang VT, Hsia TY, Yates RW, Anderson RH. Surgical repair of supposedly multiple defects within the apical part of the muscular ventricular septum. Ann Thorac Surg. 2002;73(1):58-62. 174. Rastelli G, Kirklin JW, Titus JL. Anatomic observations on complete form of persistent common atrioventricular canal with special reference to atrioventricular valves. Mayo Clin Proc. 1966;41(5):296-308. 175. Ungerleider RM. Atrial septal defects, ostium primum defects, and atrioventricular canals. In: Sabiston DC, Lyerly HK, eds. Textbook of Surgery: The Biologic Basis of Modern Surgical Practice. Philadelphia: W.B. Saunders; 1997:1993. 176. Fortuna RS, Ashburn DA, Carias De Oliveira N, Burkhart HM, Konstantinov IE, Coles JG, Smallhorn JF, Williams WG, Van Arsdell GS. | Surgery_Schwartz. Surg. 2008;136(5):1223-1228. 172. Seddio F, Reddy VM, McElhinney DB, Tworetzky W, Silverman NH, Hanley FL. Multiple ventricular septal defects: how and when should they be repaired? J Thorac Cardiovasc Surg. 1999;117(1):134-139. 173. Tsang VT, Hsia TY, Yates RW, Anderson RH. Surgical repair of supposedly multiple defects within the apical part of the muscular ventricular septum. Ann Thorac Surg. 2002;73(1):58-62. 174. Rastelli G, Kirklin JW, Titus JL. Anatomic observations on complete form of persistent common atrioventricular canal with special reference to atrioventricular valves. Mayo Clin Proc. 1966;41(5):296-308. 175. Ungerleider RM. Atrial septal defects, ostium primum defects, and atrioventricular canals. In: Sabiston DC, Lyerly HK, eds. Textbook of Surgery: The Biologic Basis of Modern Surgical Practice. Philadelphia: W.B. Saunders; 1997:1993. 176. Fortuna RS, Ashburn DA, Carias De Oliveira N, Burkhart HM, Konstantinov IE, Coles JG, Smallhorn JF, Williams WG, Van Arsdell GS. |
Surgery_Schwartz_5324 | Surgery_Schwartz | Modern Surgical Practice. Philadelphia: W.B. Saunders; 1997:1993. 176. Fortuna RS, Ashburn DA, Carias De Oliveira N, Burkhart HM, Konstantinov IE, Coles JG, Smallhorn JF, Williams WG, Van Arsdell GS. Atrioventricular septal defects: effect of bridging leaflet division on early valve function. Ann Thorac Surg. 2004;77(3):895-902; discussion 902. 177. Kouchoukos NT, Blackstone EH, Doty DB, et al. Coarcta-tion of the aorta and interrupted aortic arch. In: Kouchoukos NT, Blackstone EH, Doty DB, et al, eds. Kirklin/Barrat-Boyes Cardiac Surgery. 3rd ed. Philadelphia: Churchill Livingstone; 2003:1353. 178. Roussin R, Belli E, Lacour-Gayet F, et al. Aortic arch recon-struction with pulmonary autograft patch aortoplasty. J Tho-rac Cardiovasc Surg. 2002;123(3):443-448. 179. Brown JW, Ruzmetov M, Okada Y, Vijay P, Rodefeld MD, Turrentine MW. Outcomes in patients with interrupted aortic arch and associated anomalies: a 20-year experience. Eur J Cardiothorac Surg. 2006;29(5):666-673; discussion | Surgery_Schwartz. Modern Surgical Practice. Philadelphia: W.B. Saunders; 1997:1993. 176. Fortuna RS, Ashburn DA, Carias De Oliveira N, Burkhart HM, Konstantinov IE, Coles JG, Smallhorn JF, Williams WG, Van Arsdell GS. Atrioventricular septal defects: effect of bridging leaflet division on early valve function. Ann Thorac Surg. 2004;77(3):895-902; discussion 902. 177. Kouchoukos NT, Blackstone EH, Doty DB, et al. Coarcta-tion of the aorta and interrupted aortic arch. In: Kouchoukos NT, Blackstone EH, Doty DB, et al, eds. Kirklin/Barrat-Boyes Cardiac Surgery. 3rd ed. Philadelphia: Churchill Livingstone; 2003:1353. 178. Roussin R, Belli E, Lacour-Gayet F, et al. Aortic arch recon-struction with pulmonary autograft patch aortoplasty. J Tho-rac Cardiovasc Surg. 2002;123(3):443-448. 179. Brown JW, Ruzmetov M, Okada Y, Vijay P, Rodefeld MD, Turrentine MW. Outcomes in patients with interrupted aortic arch and associated anomalies: a 20-year experience. Eur J Cardiothorac Surg. 2006;29(5):666-673; discussion |
Surgery_Schwartz_5325 | Surgery_Schwartz | Okada Y, Vijay P, Rodefeld MD, Turrentine MW. Outcomes in patients with interrupted aortic arch and associated anomalies: a 20-year experience. Eur J Cardiothorac Surg. 2006;29(5):666-673; discussion 673-674. 180. Extracorporeal Life Support Organization. ECLS registry report. Available at: https://www.elso.org/Registry/Statistics.aspx. Accessed May 19, 2018. 181. Murthy R, Brenes J, Dimas VV, Guleserian KJ. Ringed polytetrafluoroethylene (Gore-Tex) tunneled “chimney” graft for pediatric use of Impella 2.5 axial flow pump. J Thorac Cardiovasc Surg. 2014;147(4):1421-1422. 182. Dimas VV, Murthy R, Guleserian KJ. Utilization of the Impella 2.5 micro-axial pump in children for acute circulatory support. Catheter Cardiovasc Interv. 2014;83(2):261-262. 183. Ferro G, Murthy R, Williams D, Sebastian VA, Forbess JM, Guleserian KJ. Early outcomes with HeartWare HVAD as bridge to transplant in children: a single institution expe-rience. Artif Organs. 2016;40(1):85-89. A contemporary article | Surgery_Schwartz. Okada Y, Vijay P, Rodefeld MD, Turrentine MW. Outcomes in patients with interrupted aortic arch and associated anomalies: a 20-year experience. Eur J Cardiothorac Surg. 2006;29(5):666-673; discussion 673-674. 180. Extracorporeal Life Support Organization. ECLS registry report. Available at: https://www.elso.org/Registry/Statistics.aspx. Accessed May 19, 2018. 181. Murthy R, Brenes J, Dimas VV, Guleserian KJ. Ringed polytetrafluoroethylene (Gore-Tex) tunneled “chimney” graft for pediatric use of Impella 2.5 axial flow pump. J Thorac Cardiovasc Surg. 2014;147(4):1421-1422. 182. Dimas VV, Murthy R, Guleserian KJ. Utilization of the Impella 2.5 micro-axial pump in children for acute circulatory support. Catheter Cardiovasc Interv. 2014;83(2):261-262. 183. Ferro G, Murthy R, Williams D, Sebastian VA, Forbess JM, Guleserian KJ. Early outcomes with HeartWare HVAD as bridge to transplant in children: a single institution expe-rience. Artif Organs. 2016;40(1):85-89. A contemporary article |
Surgery_Schwartz_5326 | Surgery_Schwartz | VA, Forbess JM, Guleserian KJ. Early outcomes with HeartWare HVAD as bridge to transplant in children: a single institution expe-rience. Artif Organs. 2016;40(1):85-89. A contemporary article describing the use of left ventricular assist devices in the pediatric population. 184. Rossano JW, Dipchand AI, Edwards LB, et al; International Society for Heart and Lung Transplantation. The Registry of Brunicardi_Ch20_p0751-p0800.indd 79922/02/19 2:57 PM 800SPECIFIC CONSIDERATIONSPART IIthe International Society for Heart and Lung Transplantation: nineteenth pediatric heart transplantation report, 2016; focus theme: primary diagnostic indications for transplant. J Heart Lung Transplant. 2016;35(10):1185-1195. 185. Organ Procurement and Transplantation Network. National data. Available at: https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed May 18, 2018. 186. Reinhartz O, Maeda K, Reitz BA, et al. Changes in risk pro-file over time in the population of a | Surgery_Schwartz. VA, Forbess JM, Guleserian KJ. Early outcomes with HeartWare HVAD as bridge to transplant in children: a single institution expe-rience. Artif Organs. 2016;40(1):85-89. A contemporary article describing the use of left ventricular assist devices in the pediatric population. 184. Rossano JW, Dipchand AI, Edwards LB, et al; International Society for Heart and Lung Transplantation. The Registry of Brunicardi_Ch20_p0751-p0800.indd 79922/02/19 2:57 PM 800SPECIFIC CONSIDERATIONSPART IIthe International Society for Heart and Lung Transplantation: nineteenth pediatric heart transplantation report, 2016; focus theme: primary diagnostic indications for transplant. J Heart Lung Transplant. 2016;35(10):1185-1195. 185. Organ Procurement and Transplantation Network. National data. Available at: https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed May 18, 2018. 186. Reinhartz O, Maeda K, Reitz BA, et al. Changes in risk pro-file over time in the population of a |
Surgery_Schwartz_5327 | Surgery_Schwartz | https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed May 18, 2018. 186. Reinhartz O, Maeda K, Reitz BA, et al. Changes in risk pro-file over time in the population of a pediatric heart transplant program. Ann Thorac Surg. 2015;100(3):989-994; discussion 995. 187. Sievers HH, Leyh R, Jahnke A, et al. Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation. J Thorac Cardiovasc Surg. 1994;108(4):780-784. 188. Bailey LL, Nehlsen-Cannarella SL, Concepcion W, Jolley WB. Baboon-to-human cardiac xenotransplantation in a neo-nate. JAMA. 1985;254(23):3321-3329. 189. Murthy R, Bajona P, Bhama JK, Cooper DK. Heart xenotrans-plantation: historical background, experimental progress, and clinical prospects. Ann Thorac Surg. 2016;101(4):1605-1613. 190. O’Brien SM, Clarke DR, Jacobs JP, et al. An empirically based tool for analyzing mortality | Surgery_Schwartz. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed May 18, 2018. 186. Reinhartz O, Maeda K, Reitz BA, et al. Changes in risk pro-file over time in the population of a pediatric heart transplant program. Ann Thorac Surg. 2015;100(3):989-994; discussion 995. 187. Sievers HH, Leyh R, Jahnke A, et al. Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation. J Thorac Cardiovasc Surg. 1994;108(4):780-784. 188. Bailey LL, Nehlsen-Cannarella SL, Concepcion W, Jolley WB. Baboon-to-human cardiac xenotransplantation in a neo-nate. JAMA. 1985;254(23):3321-3329. 189. Murthy R, Bajona P, Bhama JK, Cooper DK. Heart xenotrans-plantation: historical background, experimental progress, and clinical prospects. Ann Thorac Surg. 2016;101(4):1605-1613. 190. O’Brien SM, Clarke DR, Jacobs JP, et al. An empirically based tool for analyzing mortality |
Surgery_Schwartz_5328 | Surgery_Schwartz | background, experimental progress, and clinical prospects. Ann Thorac Surg. 2016;101(4):1605-1613. 190. O’Brien SM, Clarke DR, Jacobs JP, et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:1139-1153. 191. https://www.sts.org/congenital-public-reporting-module-search. March 2017. 192. Jacobs JP, Mayer JE Jr, Mavroudis C, et al. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg. 2017;103(3):699-709. An important article to understand the STS database, outcomes reporting, and where the future of the filed of public reporting is headed. 193. Bramlet M, Olivieri L, Farooqi K, Ripley B, Coakley M. Impact of three-dimensional printing on the study and treatment of congenital heart disease. Circ Res. 2017;120(6): 904-907. This article describes the new and innovative tech-nology of three-dimensional printing and its impact on the field of | Surgery_Schwartz. background, experimental progress, and clinical prospects. Ann Thorac Surg. 2016;101(4):1605-1613. 190. O’Brien SM, Clarke DR, Jacobs JP, et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:1139-1153. 191. https://www.sts.org/congenital-public-reporting-module-search. March 2017. 192. Jacobs JP, Mayer JE Jr, Mavroudis C, et al. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg. 2017;103(3):699-709. An important article to understand the STS database, outcomes reporting, and where the future of the filed of public reporting is headed. 193. Bramlet M, Olivieri L, Farooqi K, Ripley B, Coakley M. Impact of three-dimensional printing on the study and treatment of congenital heart disease. Circ Res. 2017;120(6): 904-907. This article describes the new and innovative tech-nology of three-dimensional printing and its impact on the field of |
Surgery_Schwartz_5329 | Surgery_Schwartz | study and treatment of congenital heart disease. Circ Res. 2017;120(6): 904-907. This article describes the new and innovative tech-nology of three-dimensional printing and its impact on the field of pediatric and congenital cardiac surgery. 194. Yoo SJ, Spray T, Austin EH 3rd, Yun TJ, van Arsdell GS. Hands-on surgical training of congenital heart surgery using 3-dimensional print models. J Thorac Cardiovasc Surg. 2017 Feb 9. 195. Seghaye MC. Management of children with congenital heart defect: state of the art and future prospects. Future Cardiol. 2017;13(1):65-79. doi:10.2217/fca-2016-0039. 196. Ryan JR, Moe TG, Richardson R, Frakes DH, Nigro JJ, Pophal S. A novel approach to neonatal management of tetralogy of Fallot, with pulmonary atresia, and multiple aortopulmonary collaterals. JACC Cardiovasc Imaging. 2015;8(1):103-104. 197. Ferro G, Murthy R, Sebastian VA, Guleserian KJ, Forbess JM. Single-center experience with the Senning Proce-dure in the Current Era. Semin Thorac | Surgery_Schwartz. study and treatment of congenital heart disease. Circ Res. 2017;120(6): 904-907. This article describes the new and innovative tech-nology of three-dimensional printing and its impact on the field of pediatric and congenital cardiac surgery. 194. Yoo SJ, Spray T, Austin EH 3rd, Yun TJ, van Arsdell GS. Hands-on surgical training of congenital heart surgery using 3-dimensional print models. J Thorac Cardiovasc Surg. 2017 Feb 9. 195. Seghaye MC. Management of children with congenital heart defect: state of the art and future prospects. Future Cardiol. 2017;13(1):65-79. doi:10.2217/fca-2016-0039. 196. Ryan JR, Moe TG, Richardson R, Frakes DH, Nigro JJ, Pophal S. A novel approach to neonatal management of tetralogy of Fallot, with pulmonary atresia, and multiple aortopulmonary collaterals. JACC Cardiovasc Imaging. 2015;8(1):103-104. 197. Ferro G, Murthy R, Sebastian VA, Guleserian KJ, Forbess JM. Single-center experience with the Senning Proce-dure in the Current Era. Semin Thorac |
Surgery_Schwartz_5330 | Surgery_Schwartz | JACC Cardiovasc Imaging. 2015;8(1):103-104. 197. Ferro G, Murthy R, Sebastian VA, Guleserian KJ, Forbess JM. Single-center experience with the Senning Proce-dure in the Current Era. Semin Thorac Cardiovasc Surg. 2016;28(2):514-520. 198. Zuluaga MA, Burgos N, Mendelson AF, Taylor AM, Ourselin S. Voxelwise atlas rating for computer assisted diagnosis: Application to congenital heart diseases of the great arteries. Med Image Anal. 2015;26(1):185-194.Brunicardi_Ch20_p0751-p0800.indd 80022/02/19 2:57 PM | Surgery_Schwartz. JACC Cardiovasc Imaging. 2015;8(1):103-104. 197. Ferro G, Murthy R, Sebastian VA, Guleserian KJ, Forbess JM. Single-center experience with the Senning Proce-dure in the Current Era. Semin Thorac Cardiovasc Surg. 2016;28(2):514-520. 198. Zuluaga MA, Burgos N, Mendelson AF, Taylor AM, Ourselin S. Voxelwise atlas rating for computer assisted diagnosis: Application to congenital heart diseases of the great arteries. Med Image Anal. 2015;26(1):185-194.Brunicardi_Ch20_p0751-p0800.indd 80022/02/19 2:57 PM |
Surgery_Schwartz_5331 | Surgery_Schwartz | Acquired Heart DiseaseMatthew R. Schill, Ali J. Khiabani, Puja Kachroo, and Ralph J. Damiano Jr 21chapterCardiac Assessment 801Clinical Evaluation / 801History / 801Physical Examination / 803Cardiac Risk Assessment in Noncardiac Surgery Patients / 804Diagnostic Studies / 804Extracorporeal Perfusion 807History / 807Technique / 807Adverse Effects / 808Myocardial Protection / 808Coronary Artery Disease 808History / 808Etiology and Pathogenesis / 809Risk Factors and Prevention / 809Clinical Manifestations / 809Preoperative Evaluation / 809Coronary Artery Bypass Grafting 809Indications / 809Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting / 810Summary / 811Operative Techniques and Results / 811New Developments / 814Valvular Heart Disease 814General Principles / 814Surgical Options / 815Mitral Valve Disease 817Mitral Stenosis / 817Mitral Regurgitation / 819Mitral Valve Operative Techniques and Results / 821Aortic Valve Disease 823Aortic Stenosis / 823Aortic | Surgery_Schwartz. Acquired Heart DiseaseMatthew R. Schill, Ali J. Khiabani, Puja Kachroo, and Ralph J. Damiano Jr 21chapterCardiac Assessment 801Clinical Evaluation / 801History / 801Physical Examination / 803Cardiac Risk Assessment in Noncardiac Surgery Patients / 804Diagnostic Studies / 804Extracorporeal Perfusion 807History / 807Technique / 807Adverse Effects / 808Myocardial Protection / 808Coronary Artery Disease 808History / 808Etiology and Pathogenesis / 809Risk Factors and Prevention / 809Clinical Manifestations / 809Preoperative Evaluation / 809Coronary Artery Bypass Grafting 809Indications / 809Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting / 810Summary / 811Operative Techniques and Results / 811New Developments / 814Valvular Heart Disease 814General Principles / 814Surgical Options / 815Mitral Valve Disease 817Mitral Stenosis / 817Mitral Regurgitation / 819Mitral Valve Operative Techniques and Results / 821Aortic Valve Disease 823Aortic Stenosis / 823Aortic |
Surgery_Schwartz_5332 | Surgery_Schwartz | 814Surgical Options / 815Mitral Valve Disease 817Mitral Stenosis / 817Mitral Regurgitation / 819Mitral Valve Operative Techniques and Results / 821Aortic Valve Disease 823Aortic Stenosis / 823Aortic Insufficiency / 825Aortic Valve Operative Techniques and Results / 828Tricuspid Valve Disease 829Tricuspid Stenosis and Insufficiency / 829Multivalve Disease / 831Surgical Therapy for the Failing Heart 831Epidemiology of Heart Failure / 831Etiology and Pathophysiology / 831CABG for Ischemic Cardiomyopathy / 831Secondary Mitral Regurgitation / 832Left Ventricular Aneurysmorrhaphy and Surgical Ventricular Restoration / 833Mechanical Circulatory Support / 835Right Ventricular Assist Devices and Biventricular Assist Devices / 837Total Artificial Heart / 837Surgery For Arrhythmias 837Atrial Fibrillation / 838Surgery for Pericardial Disease 839Acute Pericarditis / 839Relapsing Pericarditis / 840Chronic Constrictive Pericarditis / 840Cardiac Neoplasms 841Overview and General Clinical | Surgery_Schwartz. 814Surgical Options / 815Mitral Valve Disease 817Mitral Stenosis / 817Mitral Regurgitation / 819Mitral Valve Operative Techniques and Results / 821Aortic Valve Disease 823Aortic Stenosis / 823Aortic Insufficiency / 825Aortic Valve Operative Techniques and Results / 828Tricuspid Valve Disease 829Tricuspid Stenosis and Insufficiency / 829Multivalve Disease / 831Surgical Therapy for the Failing Heart 831Epidemiology of Heart Failure / 831Etiology and Pathophysiology / 831CABG for Ischemic Cardiomyopathy / 831Secondary Mitral Regurgitation / 832Left Ventricular Aneurysmorrhaphy and Surgical Ventricular Restoration / 833Mechanical Circulatory Support / 835Right Ventricular Assist Devices and Biventricular Assist Devices / 837Total Artificial Heart / 837Surgery For Arrhythmias 837Atrial Fibrillation / 838Surgery for Pericardial Disease 839Acute Pericarditis / 839Relapsing Pericarditis / 840Chronic Constrictive Pericarditis / 840Cardiac Neoplasms 841Overview and General Clinical |
Surgery_Schwartz_5333 | Surgery_Schwartz | Fibrillation / 838Surgery for Pericardial Disease 839Acute Pericarditis / 839Relapsing Pericarditis / 840Chronic Constrictive Pericarditis / 840Cardiac Neoplasms 841Overview and General Clinical Features / 841Myxoma / 842Other Benign Cardiac Tumors / 843Malignant Cardiac Tumors / 843Metastatic Cardiac Tumors / 843CARDIAC ASSESSMENTClinical EvaluationAs with any other field in medicine, the history and physical examination form the foundation for the evaluation of a patient with acquired heart disease requiring surgical intervention. Obtaining a complete history identifies comorbid conditions and assists in delineating the operative risks and prognosis after sur-gery. Physical examination reveals factors that may increase the complexity of surgery, such as previous surgery or the presence of peripheral arterial or cerebrovascular disease. These may influence the operative approach, but they also help guide the choice and sequence of diagnostic studies. A complete assess-ment of the | Surgery_Schwartz. Fibrillation / 838Surgery for Pericardial Disease 839Acute Pericarditis / 839Relapsing Pericarditis / 840Chronic Constrictive Pericarditis / 840Cardiac Neoplasms 841Overview and General Clinical Features / 841Myxoma / 842Other Benign Cardiac Tumors / 843Malignant Cardiac Tumors / 843Metastatic Cardiac Tumors / 843CARDIAC ASSESSMENTClinical EvaluationAs with any other field in medicine, the history and physical examination form the foundation for the evaluation of a patient with acquired heart disease requiring surgical intervention. Obtaining a complete history identifies comorbid conditions and assists in delineating the operative risks and prognosis after sur-gery. Physical examination reveals factors that may increase the complexity of surgery, such as previous surgery or the presence of peripheral arterial or cerebrovascular disease. These may influence the operative approach, but they also help guide the choice and sequence of diagnostic studies. A complete assess-ment of the |
Surgery_Schwartz_5334 | Surgery_Schwartz | of peripheral arterial or cerebrovascular disease. These may influence the operative approach, but they also help guide the choice and sequence of diagnostic studies. A complete assess-ment of the patient allows the surgeon to make educated deci-sions regarding the optimal treatment strategy for the patient.HistorySymptoms suggestive of heart disease include: chest discomfort, fatigue, edema, dyspnea, palpitations, and syncope. Adequate definition of these symptoms calls for detailed history-taking, paying particular attention to onset, intensity, radiation, dura-tion, and exacerbating or alleviating factors. The demands on the heart are determined by its loading conditions and the metabolic state of the patient. Cardiac symptoms are commonly accentuated with physical exertion or postural changes.Angina pectoris is the hallmark of coronary artery disease (CAD), but may occur with other cardiac pathologies that result in ischemia from a mismatch between the supply of oxygen by the | Surgery_Schwartz. of peripheral arterial or cerebrovascular disease. These may influence the operative approach, but they also help guide the choice and sequence of diagnostic studies. A complete assess-ment of the patient allows the surgeon to make educated deci-sions regarding the optimal treatment strategy for the patient.HistorySymptoms suggestive of heart disease include: chest discomfort, fatigue, edema, dyspnea, palpitations, and syncope. Adequate definition of these symptoms calls for detailed history-taking, paying particular attention to onset, intensity, radiation, dura-tion, and exacerbating or alleviating factors. The demands on the heart are determined by its loading conditions and the metabolic state of the patient. Cardiac symptoms are commonly accentuated with physical exertion or postural changes.Angina pectoris is the hallmark of coronary artery disease (CAD), but may occur with other cardiac pathologies that result in ischemia from a mismatch between the supply of oxygen by the |
Surgery_Schwartz_5335 | Surgery_Schwartz | changes.Angina pectoris is the hallmark of coronary artery disease (CAD), but may occur with other cardiac pathologies that result in ischemia from a mismatch between the supply of oxygen by the coronary circulation and the metabolic demand of the myo-cardium. Typically, angina is described as tightness, heaviness, or dull pain, frequently substernal, that lasts for a few minutes. This discomfort may radiate to the left arm, neck, mandible, or epigastrium. Angina is most often provoked by activities that increase metabolic demand on the heart such as exercise, eating, and states of intense emotion, and it is typically alleviated by rest or use of nitroglycerin. It is important to note that a signifi-cant number of patients with myocardial ischemia, particularly diabetics, females, and the elderly, may have “silent” angina or angina equivalents (dyspnea, diaphoresis, nausea, or fatigue). The overlap of these features with those of noncardiac etiologies Brunicardi_Ch21_p0801-p0852.indd | Surgery_Schwartz. changes.Angina pectoris is the hallmark of coronary artery disease (CAD), but may occur with other cardiac pathologies that result in ischemia from a mismatch between the supply of oxygen by the coronary circulation and the metabolic demand of the myo-cardium. Typically, angina is described as tightness, heaviness, or dull pain, frequently substernal, that lasts for a few minutes. This discomfort may radiate to the left arm, neck, mandible, or epigastrium. Angina is most often provoked by activities that increase metabolic demand on the heart such as exercise, eating, and states of intense emotion, and it is typically alleviated by rest or use of nitroglycerin. It is important to note that a signifi-cant number of patients with myocardial ischemia, particularly diabetics, females, and the elderly, may have “silent” angina or angina equivalents (dyspnea, diaphoresis, nausea, or fatigue). The overlap of these features with those of noncardiac etiologies Brunicardi_Ch21_p0801-p0852.indd |
Surgery_Schwartz_5336 | Surgery_Schwartz | elderly, may have “silent” angina or angina equivalents (dyspnea, diaphoresis, nausea, or fatigue). The overlap of these features with those of noncardiac etiologies Brunicardi_Ch21_p0801-p0852.indd 80101/03/19 5:32 PM 802such as costochondritis, biliary colic, gastroesophageal reflux disease, diffuse esophageal spasm, and peptic ulcer disease, to name a few, can sometimes lead to misdiagnosis.Heart failure can occur from either left and/or right heart dysfunction, and respective symptoms arise from congestion of blood flow owing to an inadequate cardiac output. Left heart failure manifests as dyspnea, usually with exertion. Orthopnea, defined as dyspnea while lying flat, suggests worsened pulmo-nary congestion with increased venous return. Ascites, periph-eral edema, and hepatomegaly reflect congestion in the systemic venous circulation and are prominent features of right heart failure. Peripheral edema can occur in right heart failure second-ary to systemic venous congestion or | Surgery_Schwartz. elderly, may have “silent” angina or angina equivalents (dyspnea, diaphoresis, nausea, or fatigue). The overlap of these features with those of noncardiac etiologies Brunicardi_Ch21_p0801-p0852.indd 80101/03/19 5:32 PM 802such as costochondritis, biliary colic, gastroesophageal reflux disease, diffuse esophageal spasm, and peptic ulcer disease, to name a few, can sometimes lead to misdiagnosis.Heart failure can occur from either left and/or right heart dysfunction, and respective symptoms arise from congestion of blood flow owing to an inadequate cardiac output. Left heart failure manifests as dyspnea, usually with exertion. Orthopnea, defined as dyspnea while lying flat, suggests worsened pulmo-nary congestion with increased venous return. Ascites, periph-eral edema, and hepatomegaly reflect congestion in the systemic venous circulation and are prominent features of right heart failure. Peripheral edema can occur in right heart failure second-ary to systemic venous congestion or |
Surgery_Schwartz_5337 | Surgery_Schwartz | reflect congestion in the systemic venous circulation and are prominent features of right heart failure. Peripheral edema can occur in right heart failure second-ary to systemic venous congestion or in left heart failure due to salt and fluid retention as a result of impaired renal perfusion. Patients with chronic suboptimal perfusion and oxygenation can also have digital clubbing and cyanosis.It is difficult to implicate cardiac disease based solely on the presence of fatigue, which is a very nonspecific symptom. However, most cardiac pathologies do result in fatigue or exer-cise intolerance to some degree. It is important to differenti-ate fatigue from exertional dyspnea which some patients may describe as “fatigue.”Dyspnea is another common symptom. Although gen-erally a late symptom in patients with valvular heart disease or cardiomyopathy, it may be a relatively early complaint in some patients, particularly those with mitral stenosis. As stated previously, dyspnea is also an | Surgery_Schwartz. reflect congestion in the systemic venous circulation and are prominent features of right heart failure. Peripheral edema can occur in right heart failure second-ary to systemic venous congestion or in left heart failure due to salt and fluid retention as a result of impaired renal perfusion. Patients with chronic suboptimal perfusion and oxygenation can also have digital clubbing and cyanosis.It is difficult to implicate cardiac disease based solely on the presence of fatigue, which is a very nonspecific symptom. However, most cardiac pathologies do result in fatigue or exer-cise intolerance to some degree. It is important to differenti-ate fatigue from exertional dyspnea which some patients may describe as “fatigue.”Dyspnea is another common symptom. Although gen-erally a late symptom in patients with valvular heart disease or cardiomyopathy, it may be a relatively early complaint in some patients, particularly those with mitral stenosis. As stated previously, dyspnea is also an |
Surgery_Schwartz_5338 | Surgery_Schwartz | in patients with valvular heart disease or cardiomyopathy, it may be a relatively early complaint in some patients, particularly those with mitral stenosis. As stated previously, dyspnea is also an anginal equivalent and may sig-nal a myocardial ischemic episode. Many primary pulmonary disorders feature dyspnea as their cardinal symptom and should be evaluated simultaneously as the physiology of the heart and lungs are intimately related and can have dramatic influences on one another.Patients typically describe palpitations as a “skipped beat” or “racing heart.” Depending on the clinical context, such as occasional premature atrial or ventricular beats in otherwise healthy individuals, these may be benign. Clinically significant arrhythmias, however, require thorough investigation. Atrial fibrillation is the most common arrhythmia and can occur alone or with other cardiac pathologies. It results in an irregular, and at times, rapid heartbeat. Concurrent symptoms such as angina, | Surgery_Schwartz. in patients with valvular heart disease or cardiomyopathy, it may be a relatively early complaint in some patients, particularly those with mitral stenosis. As stated previously, dyspnea is also an anginal equivalent and may sig-nal a myocardial ischemic episode. Many primary pulmonary disorders feature dyspnea as their cardinal symptom and should be evaluated simultaneously as the physiology of the heart and lungs are intimately related and can have dramatic influences on one another.Patients typically describe palpitations as a “skipped beat” or “racing heart.” Depending on the clinical context, such as occasional premature atrial or ventricular beats in otherwise healthy individuals, these may be benign. Clinically significant arrhythmias, however, require thorough investigation. Atrial fibrillation is the most common arrhythmia and can occur alone or with other cardiac pathologies. It results in an irregular, and at times, rapid heartbeat. Concurrent symptoms such as angina, |
Surgery_Schwartz_5339 | Surgery_Schwartz | Atrial fibrillation is the most common arrhythmia and can occur alone or with other cardiac pathologies. It results in an irregular, and at times, rapid heartbeat. Concurrent symptoms such as angina, lightheadedness, or syncope are particularly worrisome for life-threatening arrhythmias such as ventricular tachycardia or ventricular fibrillation, particularly in patients with preexisting heart failure.Syncope associated with heart disease results from an abrupt reduction in cerebral perfusion. Many of the potential cardiac etiologies are serious, including sinus node dysfunction, atrioventricular conduction abnormalities, malignant arrhyth-mias, aortic stenosis, and hypertrophic obstructive cardiomy-opathy. Noncardiac causes of syncope includes, but are not limited to, neurologic causes (e.g., transient ischemic attacks [TIAs]), orthostatic hypotension, vasavagal events, and carotid sinus hypersensitivity. Any episode of syncope warrants a thor-ough evaluation and search for the root | Surgery_Schwartz. Atrial fibrillation is the most common arrhythmia and can occur alone or with other cardiac pathologies. It results in an irregular, and at times, rapid heartbeat. Concurrent symptoms such as angina, lightheadedness, or syncope are particularly worrisome for life-threatening arrhythmias such as ventricular tachycardia or ventricular fibrillation, particularly in patients with preexisting heart failure.Syncope associated with heart disease results from an abrupt reduction in cerebral perfusion. Many of the potential cardiac etiologies are serious, including sinus node dysfunction, atrioventricular conduction abnormalities, malignant arrhyth-mias, aortic stenosis, and hypertrophic obstructive cardiomy-opathy. Noncardiac causes of syncope includes, but are not limited to, neurologic causes (e.g., transient ischemic attacks [TIAs]), orthostatic hypotension, vasavagal events, and carotid sinus hypersensitivity. Any episode of syncope warrants a thor-ough evaluation and search for the root |
Surgery_Schwartz_5340 | Surgery_Schwartz | transient ischemic attacks [TIAs]), orthostatic hypotension, vasavagal events, and carotid sinus hypersensitivity. Any episode of syncope warrants a thor-ough evaluation and search for the root cause.1,2 In addition to a thorough inquiry regarding the aforementioned symptoms, it is important to obtain details about the patient’s medical and Key Points1 Although advances have been made in percutaneous coro-nary intervention techniques for coronary artery disease, survival is superior with coronary artery bypass grafting in patients with left main disease, multivessel disease, and in diabetic patients.2 Despite the theoretical advantages, the superiority of off-pump coronary artery bypass to conventional coronary artery bypass grafting has not been clearly established, and other factors likely dominate the overall outcome for either technique.3 Although mechanical valves offer enhanced durability over tissue valve prosthesis, they require permanent systemic anticoagulation therapy to | Surgery_Schwartz. transient ischemic attacks [TIAs]), orthostatic hypotension, vasavagal events, and carotid sinus hypersensitivity. Any episode of syncope warrants a thor-ough evaluation and search for the root cause.1,2 In addition to a thorough inquiry regarding the aforementioned symptoms, it is important to obtain details about the patient’s medical and Key Points1 Although advances have been made in percutaneous coro-nary intervention techniques for coronary artery disease, survival is superior with coronary artery bypass grafting in patients with left main disease, multivessel disease, and in diabetic patients.2 Despite the theoretical advantages, the superiority of off-pump coronary artery bypass to conventional coronary artery bypass grafting has not been clearly established, and other factors likely dominate the overall outcome for either technique.3 Although mechanical valves offer enhanced durability over tissue valve prosthesis, they require permanent systemic anticoagulation therapy to |
Surgery_Schwartz_5341 | Surgery_Schwartz | dominate the overall outcome for either technique.3 Although mechanical valves offer enhanced durability over tissue valve prosthesis, they require permanent systemic anticoagulation therapy to mitigate the risk of valve throm-bosis and thromboembolic sequelae and thus are associated with an increased risk of hemorrhagic complications.4 Mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic mitral regurgitation. The decision to proceed with mitral valve repair is based on the skill and experience of the sur-geon in performing the repair and on the pathology of mitral valve disease encountered at the time of operation. Trans-catheter mitral valve therapies are also becoming increas-ingly available as options to offer patients who are deemed high risk for surgical intervention for their mitral valve disease.5 Although open aortic valve replacement has traditionally been the only effective treatment in patients with severe | Surgery_Schwartz. dominate the overall outcome for either technique.3 Although mechanical valves offer enhanced durability over tissue valve prosthesis, they require permanent systemic anticoagulation therapy to mitigate the risk of valve throm-bosis and thromboembolic sequelae and thus are associated with an increased risk of hemorrhagic complications.4 Mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic mitral regurgitation. The decision to proceed with mitral valve repair is based on the skill and experience of the sur-geon in performing the repair and on the pathology of mitral valve disease encountered at the time of operation. Trans-catheter mitral valve therapies are also becoming increas-ingly available as options to offer patients who are deemed high risk for surgical intervention for their mitral valve disease.5 Although open aortic valve replacement has traditionally been the only effective treatment in patients with severe |
Surgery_Schwartz_5342 | Surgery_Schwartz | who are deemed high risk for surgical intervention for their mitral valve disease.5 Although open aortic valve replacement has traditionally been the only effective treatment in patients with severe cal-cific aortic stenosis, transcatheter aortic valve replacement is a developing technology that has proven beneficial for the treatment of aortic stenosis in seriously ill patients that had previously been deemed high risk or inoperable. It has also recently been approved for us in patients at moderate risk for surgical aortic valve replacement and is in clinical trials for low-risk patients.6 Mechanical circulatory support with newer generation con-tinuous flow left ventricular assist devices has proven to be durable and effective both as a bridge to transplant and as a means of destination therapy for patients who are not trans-plant candidates.7 Performing a biatrial Cox-Maze lesion set results in freedom from atrial fibrillation in approximately 90% of patients and is superior to | Surgery_Schwartz. who are deemed high risk for surgical intervention for their mitral valve disease.5 Although open aortic valve replacement has traditionally been the only effective treatment in patients with severe cal-cific aortic stenosis, transcatheter aortic valve replacement is a developing technology that has proven beneficial for the treatment of aortic stenosis in seriously ill patients that had previously been deemed high risk or inoperable. It has also recently been approved for us in patients at moderate risk for surgical aortic valve replacement and is in clinical trials for low-risk patients.6 Mechanical circulatory support with newer generation con-tinuous flow left ventricular assist devices has proven to be durable and effective both as a bridge to transplant and as a means of destination therapy for patients who are not trans-plant candidates.7 Performing a biatrial Cox-Maze lesion set results in freedom from atrial fibrillation in approximately 90% of patients and is superior to |
Surgery_Schwartz_5343 | Surgery_Schwartz | therapy for patients who are not trans-plant candidates.7 Performing a biatrial Cox-Maze lesion set results in freedom from atrial fibrillation in approximately 90% of patients and is superior to both catheter-ablation and more limited lesion sets for patients with persistent atrial fibrillation or enlarged left atria. Surgical ablation of atrial fibrillation is recom-mended for patients referred with concomitant valvular dis-ease and those who have previously failed or are poor candidates for catheter-based approaches.8 The preferred treatment for pericarditis depends on the underlying cause, although the disease typically follows a self-limited course and is best managed medically. Surgical pericardiectomy may have a role in treating relapsing peri-carditis and, more commonly, chronic constrictive pericarditis.9 Myxomas are the most common cardiac tumors, and, while benign, they should be promptly excised after diagnosis due to the risk of embolization, obstructive complications, | Surgery_Schwartz. therapy for patients who are not trans-plant candidates.7 Performing a biatrial Cox-Maze lesion set results in freedom from atrial fibrillation in approximately 90% of patients and is superior to both catheter-ablation and more limited lesion sets for patients with persistent atrial fibrillation or enlarged left atria. Surgical ablation of atrial fibrillation is recom-mended for patients referred with concomitant valvular dis-ease and those who have previously failed or are poor candidates for catheter-based approaches.8 The preferred treatment for pericarditis depends on the underlying cause, although the disease typically follows a self-limited course and is best managed medically. Surgical pericardiectomy may have a role in treating relapsing peri-carditis and, more commonly, chronic constrictive pericarditis.9 Myxomas are the most common cardiac tumors, and, while benign, they should be promptly excised after diagnosis due to the risk of embolization, obstructive complications, |
Surgery_Schwartz_5344 | Surgery_Schwartz | constrictive pericarditis.9 Myxomas are the most common cardiac tumors, and, while benign, they should be promptly excised after diagnosis due to the risk of embolization, obstructive complications, and arrhythmias.Brunicardi_Ch21_p0801-p0852.indd 80201/03/19 5:32 PM 803ACQUIRED HEART DISEASECHAPTER 21Table 21-1New York Heart Association (NYHA) functional classificationCLASSDESCRIPTIONIPhysical activity not limited by symptoms: fatigue, palpitations, or dyspnea.IIComfortable at rest. Slight limitation of physical activity. Fatigue, palpitations, or dyspnea with ordinary physical activity.IIIComfortable at rest. Marked limitation of physical activity. Fatigue, palpitations, or dyspnea with less than ordinary physical activity.IVInability to carry out any physical activity. Symptoms may be present at rest and increase with activity.Table 21-2Canadian Cardiovascular Society (CCS) angina classificationCLASSDESCRIPTIONIOrdinary physical activity (walking, climbing stairs) does not | Surgery_Schwartz. constrictive pericarditis.9 Myxomas are the most common cardiac tumors, and, while benign, they should be promptly excised after diagnosis due to the risk of embolization, obstructive complications, and arrhythmias.Brunicardi_Ch21_p0801-p0852.indd 80201/03/19 5:32 PM 803ACQUIRED HEART DISEASECHAPTER 21Table 21-1New York Heart Association (NYHA) functional classificationCLASSDESCRIPTIONIPhysical activity not limited by symptoms: fatigue, palpitations, or dyspnea.IIComfortable at rest. Slight limitation of physical activity. Fatigue, palpitations, or dyspnea with ordinary physical activity.IIIComfortable at rest. Marked limitation of physical activity. Fatigue, palpitations, or dyspnea with less than ordinary physical activity.IVInability to carry out any physical activity. Symptoms may be present at rest and increase with activity.Table 21-2Canadian Cardiovascular Society (CCS) angina classificationCLASSDESCRIPTIONIOrdinary physical activity (walking, climbing stairs) does not |
Surgery_Schwartz_5345 | Surgery_Schwartz | may be present at rest and increase with activity.Table 21-2Canadian Cardiovascular Society (CCS) angina classificationCLASSDESCRIPTIONIOrdinary physical activity (walking, climbing stairs) does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion during work or recreation.IISlight limitation of ordinary activity. Angina occurs with climbing stairs rapidly, walking uphill in the wind, under emotional stress, in the cold, or after meals. Walking more than 2 blocks or climbing one flight of stairs causes angina.IIIMarked limitation of ordinary physical activity (climbing a flight of stairs or walking 1 to 2 blocks at a normal pace).IVInability to carry out any physical activity without discomfort. Angina may be present at rest.surgical history, family history, social habits (including alcohol and tobacco use), current medications, focused review of sys-tems, as well as an assessment of the patient’s functional status and frailty. Frailty is often defined as a | Surgery_Schwartz. may be present at rest and increase with activity.Table 21-2Canadian Cardiovascular Society (CCS) angina classificationCLASSDESCRIPTIONIOrdinary physical activity (walking, climbing stairs) does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion during work or recreation.IISlight limitation of ordinary activity. Angina occurs with climbing stairs rapidly, walking uphill in the wind, under emotional stress, in the cold, or after meals. Walking more than 2 blocks or climbing one flight of stairs causes angina.IIIMarked limitation of ordinary physical activity (climbing a flight of stairs or walking 1 to 2 blocks at a normal pace).IVInability to carry out any physical activity without discomfort. Angina may be present at rest.surgical history, family history, social habits (including alcohol and tobacco use), current medications, focused review of sys-tems, as well as an assessment of the patient’s functional status and frailty. Frailty is often defined as a |
Surgery_Schwartz_5346 | Surgery_Schwartz | habits (including alcohol and tobacco use), current medications, focused review of sys-tems, as well as an assessment of the patient’s functional status and frailty. Frailty is often defined as a state of increased vul-nerability to adverse health outcomes. Clinicians can use frailty index calculators to assess a patient’s risk for adverse outcomes following cardiac intervention. Specific attention should also be directed to the patient’s comorbidities which not only sheds light on their general health but also helps delineate expected risks from surgery. A strong family history of coronary artery disease, myocardial infarction, hypertension, or diabetes is of particular importance as they increase the individual’s risk for having an adverse cardiac event.Functional Disability and Angina. With regard to heart failure, functional capacity is strongly correlated with mortality. The New York Heart Association (NYHA) functional class is a widely used classification system in categorizing | Surgery_Schwartz. habits (including alcohol and tobacco use), current medications, focused review of sys-tems, as well as an assessment of the patient’s functional status and frailty. Frailty is often defined as a state of increased vul-nerability to adverse health outcomes. Clinicians can use frailty index calculators to assess a patient’s risk for adverse outcomes following cardiac intervention. Specific attention should also be directed to the patient’s comorbidities which not only sheds light on their general health but also helps delineate expected risks from surgery. A strong family history of coronary artery disease, myocardial infarction, hypertension, or diabetes is of particular importance as they increase the individual’s risk for having an adverse cardiac event.Functional Disability and Angina. With regard to heart failure, functional capacity is strongly correlated with mortality. The New York Heart Association (NYHA) functional class is a widely used classification system in categorizing |
Surgery_Schwartz_5347 | Surgery_Schwartz | regard to heart failure, functional capacity is strongly correlated with mortality. The New York Heart Association (NYHA) functional class is a widely used classification system in categorizing patients based on their functional status (Table 21-1).3 The NYHA clas-sification has become one basis by which to compare patient populations in many studies. Although less commonly used, the Canadian Cardiovascular Society (CCS) angina classification is also used to incorporate anginal symptoms into the functional assessment for prognostic value (Table 21-2).Physical ExaminationThe physical examination is an invaluable tool in directing further diagnostic studies in the management of a patient with suspected heart disease. The astute clinician may be able to detect subtle signs that may further characterize the underlying pathology.The general appearance of a patient is important in the clinical assessment. A pale, diaphoretic, and obviously uncom-fortable patient is more likely to be in a | Surgery_Schwartz. regard to heart failure, functional capacity is strongly correlated with mortality. The New York Heart Association (NYHA) functional class is a widely used classification system in categorizing patients based on their functional status (Table 21-1).3 The NYHA clas-sification has become one basis by which to compare patient populations in many studies. Although less commonly used, the Canadian Cardiovascular Society (CCS) angina classification is also used to incorporate anginal symptoms into the functional assessment for prognostic value (Table 21-2).Physical ExaminationThe physical examination is an invaluable tool in directing further diagnostic studies in the management of a patient with suspected heart disease. The astute clinician may be able to detect subtle signs that may further characterize the underlying pathology.The general appearance of a patient is important in the clinical assessment. A pale, diaphoretic, and obviously uncom-fortable patient is more likely to be in a |
Surgery_Schwartz_5348 | Surgery_Schwartz | characterize the underlying pathology.The general appearance of a patient is important in the clinical assessment. A pale, diaphoretic, and obviously uncom-fortable patient is more likely to be in a clinically critical condition than one who is conversing comfortably with an unre-markable demeanor. In addition to basic vital signs, particular attention should be directed to the patient’s mental status as well as the color and temperature of the skin, as these may be reflec-tive of the general adequacy of perfusion. Overall frailty and dementia have also been shown to be predictors of operative and late mortality.4Palpation of the precordium may demonstrate devia-tion in the point of maximal impulse, indicative of ventricular hypertrophy, or parasternal heaves, seen in right ventricular overload. Auscultation should be performed in a quiet envi-ronment as critical murmurs, rubs, or gallops may be subtle. Murmurs are characterized by their location, timing, quality, and radiation. They | Surgery_Schwartz. characterize the underlying pathology.The general appearance of a patient is important in the clinical assessment. A pale, diaphoretic, and obviously uncom-fortable patient is more likely to be in a clinically critical condition than one who is conversing comfortably with an unre-markable demeanor. In addition to basic vital signs, particular attention should be directed to the patient’s mental status as well as the color and temperature of the skin, as these may be reflec-tive of the general adequacy of perfusion. Overall frailty and dementia have also been shown to be predictors of operative and late mortality.4Palpation of the precordium may demonstrate devia-tion in the point of maximal impulse, indicative of ventricular hypertrophy, or parasternal heaves, seen in right ventricular overload. Auscultation should be performed in a quiet envi-ronment as critical murmurs, rubs, or gallops may be subtle. Murmurs are characterized by their location, timing, quality, and radiation. They |
Surgery_Schwartz_5349 | Surgery_Schwartz | Auscultation should be performed in a quiet envi-ronment as critical murmurs, rubs, or gallops may be subtle. Murmurs are characterized by their location, timing, quality, and radiation. They are typically secondary to valvular or other structural pathology, and new findings require further investi-gation. A rub due to pericardial friction is indicative of pericar-ditis. A third heart sound (S3) is generated by the rapid filling of a stiff ventricle and can be normal in young patients, but when present in older adults, is indicative of diastolic dysfunction and is pathologic. Increased contribution of the atrial pump function to ventricular filling may manifest as a fourth heart sound (S4) and is also suggestive of ventricular dysfunction.Palpation of peripheral pulses is important not only to assess the adequacy of perfusion, but also the burden of coro-nary artery disease often correlates with the degree of peripheral arterial disease. The presence of a carotid bruit may indicate | Surgery_Schwartz. Auscultation should be performed in a quiet envi-ronment as critical murmurs, rubs, or gallops may be subtle. Murmurs are characterized by their location, timing, quality, and radiation. They are typically secondary to valvular or other structural pathology, and new findings require further investi-gation. A rub due to pericardial friction is indicative of pericar-ditis. A third heart sound (S3) is generated by the rapid filling of a stiff ventricle and can be normal in young patients, but when present in older adults, is indicative of diastolic dysfunction and is pathologic. Increased contribution of the atrial pump function to ventricular filling may manifest as a fourth heart sound (S4) and is also suggestive of ventricular dysfunction.Palpation of peripheral pulses is important not only to assess the adequacy of perfusion, but also the burden of coro-nary artery disease often correlates with the degree of peripheral arterial disease. The presence of a carotid bruit may indicate |
Surgery_Schwartz_5350 | Surgery_Schwartz | only to assess the adequacy of perfusion, but also the burden of coro-nary artery disease often correlates with the degree of peripheral arterial disease. The presence of a carotid bruit may indicate clinically significant stenosis and may alter the course and tim-ing of treatment, especially if symptomatic.Heart failure will frequently have extracardiac manifesta-tions and examination of the other organ systems should not be neglected. For example, auscultation of the lung fields may reveal rales in patients with pulmonary edema. The use of acces-sory muscles of breathing may be present in patients with sig-nificant pleural effusions and volume overload. The presence of jugular venous distention and hepatosplenomegaly may signal right heart failure.Additionally, clinicians should know the manifestation of other cardiac pathologies including endocarditis and rheu-matic heart disease, although less commonly seen. Endocarditis is an inflammation of the endocardium, usually on the heart | Surgery_Schwartz. only to assess the adequacy of perfusion, but also the burden of coro-nary artery disease often correlates with the degree of peripheral arterial disease. The presence of a carotid bruit may indicate clinically significant stenosis and may alter the course and tim-ing of treatment, especially if symptomatic.Heart failure will frequently have extracardiac manifesta-tions and examination of the other organ systems should not be neglected. For example, auscultation of the lung fields may reveal rales in patients with pulmonary edema. The use of acces-sory muscles of breathing may be present in patients with sig-nificant pleural effusions and volume overload. The presence of jugular venous distention and hepatosplenomegaly may signal right heart failure.Additionally, clinicians should know the manifestation of other cardiac pathologies including endocarditis and rheu-matic heart disease, although less commonly seen. Endocarditis is an inflammation of the endocardium, usually on the heart |
Surgery_Schwartz_5351 | Surgery_Schwartz | manifestation of other cardiac pathologies including endocarditis and rheu-matic heart disease, although less commonly seen. Endocarditis is an inflammation of the endocardium, usually on the heart valves. A cardiac murmur is a common physical exam finding. Relatively uncommon but more specific clinical manifestations for infectious endocarditis are: Janeway lesions, which are nontender erythematous macules on the palms and soles; Osler nodes, which are described as tender subctanous nodules mostly on the pads of the fingers and toes; and Roth spots, which are exudative hemorrhagic lesions of the retina with pale centers.Brunicardi_Ch21_p0801-p0852.indd 80301/03/19 5:32 PM 804SPECIFIC CONSIDERATIONSPART IICardiac Risk Assessment in Noncardiac Surgery PatientsCardiovascular complications occur in approximately 3% of patients undergoing inpatient noncardiac surgery.5 The American College of Cardiology (ACC) and American Heart Association (AHA) have formed a joint task force to | Surgery_Schwartz. manifestation of other cardiac pathologies including endocarditis and rheu-matic heart disease, although less commonly seen. Endocarditis is an inflammation of the endocardium, usually on the heart valves. A cardiac murmur is a common physical exam finding. Relatively uncommon but more specific clinical manifestations for infectious endocarditis are: Janeway lesions, which are nontender erythematous macules on the palms and soles; Osler nodes, which are described as tender subctanous nodules mostly on the pads of the fingers and toes; and Roth spots, which are exudative hemorrhagic lesions of the retina with pale centers.Brunicardi_Ch21_p0801-p0852.indd 80301/03/19 5:32 PM 804SPECIFIC CONSIDERATIONSPART IICardiac Risk Assessment in Noncardiac Surgery PatientsCardiovascular complications occur in approximately 3% of patients undergoing inpatient noncardiac surgery.5 The American College of Cardiology (ACC) and American Heart Association (AHA) have formed a joint task force to |
Surgery_Schwartz_5352 | Surgery_Schwartz | occur in approximately 3% of patients undergoing inpatient noncardiac surgery.5 The American College of Cardiology (ACC) and American Heart Association (AHA) have formed a joint task force to publish a consensus statement, with periodic focused updates, on guide-lines and recommendations that were revised in 2017.6 The aim of these guidelines is to incorporate surgery-specific risks and patient characteristics to guide perioperative decision-making in the management of patient with valvular heart disease.Surgical procedures have been categorized based on cardiovascular risk into low risk, moderate risk, and vascu-lar procedures. Vascular procedures, likely due to both the nature of the procedures themselves as well as the associated cardiovascular pathology in many of these patients, carry the highest reported risk of cardiac events at more than 7%.5 Low risk procedures, including endoscopic procedures, superficial operations, cataract surgery, breast surgery, and ambulatory | Surgery_Schwartz. occur in approximately 3% of patients undergoing inpatient noncardiac surgery.5 The American College of Cardiology (ACC) and American Heart Association (AHA) have formed a joint task force to publish a consensus statement, with periodic focused updates, on guide-lines and recommendations that were revised in 2017.6 The aim of these guidelines is to incorporate surgery-specific risks and patient characteristics to guide perioperative decision-making in the management of patient with valvular heart disease.Surgical procedures have been categorized based on cardiovascular risk into low risk, moderate risk, and vascu-lar procedures. Vascular procedures, likely due to both the nature of the procedures themselves as well as the associated cardiovascular pathology in many of these patients, carry the highest reported risk of cardiac events at more than 7%.5 Low risk procedures, including endoscopic procedures, superficial operations, cataract surgery, breast surgery, and ambulatory |
Surgery_Schwartz_5353 | Surgery_Schwartz | carry the highest reported risk of cardiac events at more than 7%.5 Low risk procedures, including endoscopic procedures, superficial operations, cataract surgery, breast surgery, and ambulatory surgeries, have a risk generally less than 1%. Intermediate risk procedures include intraperitoneal and intrathoracic surgery, head and neck surgery, orthopedic procedures, and prostate surgery.5Patient characteristics can be classified by the status of the patient’s cardiac disease, comorbid conditions, and functional capacity. Patients are considered to be at major perioperative clinical risk if they have one or more of the following active car-diac conditions: acute coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular heart disease. In these patients, intensive evaluation and treatment prior to sur-gery (unless emergent) is warranted, prior to proceeding with the noncardiac surgery.If the patient does not have any of the previously men-tioned active | Surgery_Schwartz. carry the highest reported risk of cardiac events at more than 7%.5 Low risk procedures, including endoscopic procedures, superficial operations, cataract surgery, breast surgery, and ambulatory surgeries, have a risk generally less than 1%. Intermediate risk procedures include intraperitoneal and intrathoracic surgery, head and neck surgery, orthopedic procedures, and prostate surgery.5Patient characteristics can be classified by the status of the patient’s cardiac disease, comorbid conditions, and functional capacity. Patients are considered to be at major perioperative clinical risk if they have one or more of the following active car-diac conditions: acute coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular heart disease. In these patients, intensive evaluation and treatment prior to sur-gery (unless emergent) is warranted, prior to proceeding with the noncardiac surgery.If the patient does not have any of the previously men-tioned active |
Surgery_Schwartz_5354 | Surgery_Schwartz | evaluation and treatment prior to sur-gery (unless emergent) is warranted, prior to proceeding with the noncardiac surgery.If the patient does not have any of the previously men-tioned active cardiac conditions, the perioperative risk of major adverse cardiac events (MACE) should be estimated. Both the operation performed and the patient’s risk factors are predictive of MACE, and the ACC/AHA guidelines recommend the use of either the American College of Surgeons’ NSQIP risk calculator or the Revised Cardiac Risk Index for the estimation of patient-specific risk. Patients at low (<1%) risk or patients at elevated risk with functional capacity greater than or equal to 4 metabolic equivalents (METs), should proceed to surgery without further testing. It is reasonable to perform pharmacologic stress testing in patients with poor or unknown functional capacity if this test-ing will impact decision making or perioperative care. Patients with abnormal stress test results should undergo | Surgery_Schwartz. evaluation and treatment prior to sur-gery (unless emergent) is warranted, prior to proceeding with the noncardiac surgery.If the patient does not have any of the previously men-tioned active cardiac conditions, the perioperative risk of major adverse cardiac events (MACE) should be estimated. Both the operation performed and the patient’s risk factors are predictive of MACE, and the ACC/AHA guidelines recommend the use of either the American College of Surgeons’ NSQIP risk calculator or the Revised Cardiac Risk Index for the estimation of patient-specific risk. Patients at low (<1%) risk or patients at elevated risk with functional capacity greater than or equal to 4 metabolic equivalents (METs), should proceed to surgery without further testing. It is reasonable to perform pharmacologic stress testing in patients with poor or unknown functional capacity if this test-ing will impact decision making or perioperative care. Patients with abnormal stress test results should undergo |
Surgery_Schwartz_5355 | Surgery_Schwartz | stress testing in patients with poor or unknown functional capacity if this test-ing will impact decision making or perioperative care. Patients with abnormal stress test results should undergo confirmatory test such as coronary angiography, if indicated, before an elec-tive noncardiac surgery. The previous guidelines included inter-mediate and low cardiovascular risk profiles, but this has been replaced by cardiovascular risk factors in the update. These risk factors are: history of ischemic heart disease, history of prior or compensated heart failure, history of cerebrovascular dis-ease, diabetes mellitus, and renal insufficiency. Based on the number of present risk factors and the surgery-specific risk, the guidelines recommend pathways for further evaluation and risk management. The most recent guidelines from ACC/AHA were published in 2014 (Fig. 21-1).7 One important subgroup of patients at elevated risk are those who have recently undergone percutaneous coronary intervention. In | Surgery_Schwartz. stress testing in patients with poor or unknown functional capacity if this test-ing will impact decision making or perioperative care. Patients with abnormal stress test results should undergo confirmatory test such as coronary angiography, if indicated, before an elec-tive noncardiac surgery. The previous guidelines included inter-mediate and low cardiovascular risk profiles, but this has been replaced by cardiovascular risk factors in the update. These risk factors are: history of ischemic heart disease, history of prior or compensated heart failure, history of cerebrovascular dis-ease, diabetes mellitus, and renal insufficiency. Based on the number of present risk factors and the surgery-specific risk, the guidelines recommend pathways for further evaluation and risk management. The most recent guidelines from ACC/AHA were published in 2014 (Fig. 21-1).7 One important subgroup of patients at elevated risk are those who have recently undergone percutaneous coronary intervention. In |
Surgery_Schwartz_5356 | Surgery_Schwartz | recent guidelines from ACC/AHA were published in 2014 (Fig. 21-1).7 One important subgroup of patients at elevated risk are those who have recently undergone percutaneous coronary intervention. In these patients, elective noncardiac surgery should be delayed until the risk of stent thrombosis decreases (30 days for bare metal stents and 180 to 365 days for drug-eluting stents), and dual antiplatelet therapy should be continued unless the risk of bleeding exceeds the risk of stent thrombosis.5Diagnostic StudiesElectrocardiogram and Chest X-ray. Electrocardiograms (ECGs) and chest X-rays are noninvasive diagnostic studies that provide invaluable information in the preoperative assess-ment of patients with cardiac pathology. ECGs can be useful in detecting old myocardial infarction, dilation or hypertrophy of the cardiac chambers, arrhythmias, and conduction abnormali-ties. A stress ECG requires a patient to exercise to a target heart rate and is used to help diagnose ischemic | Surgery_Schwartz. recent guidelines from ACC/AHA were published in 2014 (Fig. 21-1).7 One important subgroup of patients at elevated risk are those who have recently undergone percutaneous coronary intervention. In these patients, elective noncardiac surgery should be delayed until the risk of stent thrombosis decreases (30 days for bare metal stents and 180 to 365 days for drug-eluting stents), and dual antiplatelet therapy should be continued unless the risk of bleeding exceeds the risk of stent thrombosis.5Diagnostic StudiesElectrocardiogram and Chest X-ray. Electrocardiograms (ECGs) and chest X-rays are noninvasive diagnostic studies that provide invaluable information in the preoperative assess-ment of patients with cardiac pathology. ECGs can be useful in detecting old myocardial infarction, dilation or hypertrophy of the cardiac chambers, arrhythmias, and conduction abnormali-ties. A stress ECG requires a patient to exercise to a target heart rate and is used to help diagnose ischemic |
Surgery_Schwartz_5357 | Surgery_Schwartz | dilation or hypertrophy of the cardiac chambers, arrhythmias, and conduction abnormali-ties. A stress ECG requires a patient to exercise to a target heart rate and is used to help diagnose ischemic pathologies that may not be evident at rest.A plain film of the chest can detect pulmonary pathol-ogy, sequelae of heart failure (e.g., pulmonary edema, cardiac enlargement, pleural effusions), as well as presence of hardware (e.g., prosthetic heart valves, sternal wires, pacemakers, and defibrillators).Echocardiography. Echocardiography utilizes reflected sound waves to image the heart. Transthoracic echocardiography (TTE) is used widely due to its noninvasive nature. It is the pri-mary diagnostic tool used to evaluate structural diseases of the heart, including valvular pathology, septal defects, cardiomyop-athies, and cardiac masses. Although more invasive, transesoph-ageal echocardiography (TEE) can provide more information and better definition of some valvular and structural | Surgery_Schwartz. dilation or hypertrophy of the cardiac chambers, arrhythmias, and conduction abnormali-ties. A stress ECG requires a patient to exercise to a target heart rate and is used to help diagnose ischemic pathologies that may not be evident at rest.A plain film of the chest can detect pulmonary pathol-ogy, sequelae of heart failure (e.g., pulmonary edema, cardiac enlargement, pleural effusions), as well as presence of hardware (e.g., prosthetic heart valves, sternal wires, pacemakers, and defibrillators).Echocardiography. Echocardiography utilizes reflected sound waves to image the heart. Transthoracic echocardiography (TTE) is used widely due to its noninvasive nature. It is the pri-mary diagnostic tool used to evaluate structural diseases of the heart, including valvular pathology, septal defects, cardiomyop-athies, and cardiac masses. Although more invasive, transesoph-ageal echocardiography (TEE) can provide more information and better definition of some valvular and structural |
Surgery_Schwartz_5358 | Surgery_Schwartz | defects, cardiomyop-athies, and cardiac masses. Although more invasive, transesoph-ageal echocardiography (TEE) can provide more information and better definition of some valvular and structural abnormali-ties. It is particularly useful in identifying left atrial thrombi in patients with atrial fibrillation. Echocardiography is indispens-able in assessing surgical prostheses such as valves, leads, or mechanical circulatory support devices. These examinations can be performed with M-mode imaging (motion along a single line) as well as two-dimensional (2D) and three-dimensional (3D) imaging depending on the information required.Doppler technology has become a standard addition to assess changes in flow patterns across dysfunctional valves. Velocity measurements can be obtained to estimate pres-sure gradients across structures using the continuity equation. A common example would be the estimation of pulmonary arterial systolic pressure calculated from the regurgitant tricuspid jet | Surgery_Schwartz. defects, cardiomyop-athies, and cardiac masses. Although more invasive, transesoph-ageal echocardiography (TEE) can provide more information and better definition of some valvular and structural abnormali-ties. It is particularly useful in identifying left atrial thrombi in patients with atrial fibrillation. Echocardiography is indispens-able in assessing surgical prostheses such as valves, leads, or mechanical circulatory support devices. These examinations can be performed with M-mode imaging (motion along a single line) as well as two-dimensional (2D) and three-dimensional (3D) imaging depending on the information required.Doppler technology has become a standard addition to assess changes in flow patterns across dysfunctional valves. Velocity measurements can be obtained to estimate pres-sure gradients across structures using the continuity equation. A common example would be the estimation of pulmonary arterial systolic pressure calculated from the regurgitant tricuspid jet |
Surgery_Schwartz_5359 | Surgery_Schwartz | pres-sure gradients across structures using the continuity equation. A common example would be the estimation of pulmonary arterial systolic pressure calculated from the regurgitant tricuspid jet profile during right ventricular systole.Transthoracic echocardiography requires no sedation and is generally performed with the patient in a slight left lateral decubitus position. Standardized views are obtained with the ultrasound probe placed in the apical, parasternal, subcostal, and suprasternal positions. The apical four-chamber view is a use-ful window for visualizing all four cardiac chambers simultane-ously as well as the tricuspid and mitral valves. Other windows can be obtained to assess specific structures such as the individ-ual valve anatomy or myocardial wall segments. Dobutamine-stress echocardiography is a study similar in idea to the stress ECG that utilizes a pharmacologic agent to assess the patient for ischemia or stress-induced valvular abnormalities.Transesophageal | Surgery_Schwartz. pres-sure gradients across structures using the continuity equation. A common example would be the estimation of pulmonary arterial systolic pressure calculated from the regurgitant tricuspid jet profile during right ventricular systole.Transthoracic echocardiography requires no sedation and is generally performed with the patient in a slight left lateral decubitus position. Standardized views are obtained with the ultrasound probe placed in the apical, parasternal, subcostal, and suprasternal positions. The apical four-chamber view is a use-ful window for visualizing all four cardiac chambers simultane-ously as well as the tricuspid and mitral valves. Other windows can be obtained to assess specific structures such as the individ-ual valve anatomy or myocardial wall segments. Dobutamine-stress echocardiography is a study similar in idea to the stress ECG that utilizes a pharmacologic agent to assess the patient for ischemia or stress-induced valvular abnormalities.Transesophageal |
Surgery_Schwartz_5360 | Surgery_Schwartz | echocardiography is a study similar in idea to the stress ECG that utilizes a pharmacologic agent to assess the patient for ischemia or stress-induced valvular abnormalities.Transesophageal echocardiography, on the other hand, is performed using a special endoscope with an ultrasound probe mounted on its end that is introduced orally into the esophagus under sedation. Posterior structures such as the mitral valve and left atrium are particularly well visualized. TEEs are frequently used intraoperatively during cardiothoracic surgery to assess global cardiac function, integrity of valve repairs and replace-ments, intracavitary thrombus and/or air, and aortic athero-sclerosis or dissections that can have significant influences on operative strategy.Brunicardi_Ch21_p0801-p0852.indd 80401/03/19 5:32 PM 805ACQUIRED HEART DISEASECHAPTER 21Figure 21-1. Stepwise approach to perioperative cardiac assessment for coronary artery disease. (Reproduced with permission from Fleisher LA, | Surgery_Schwartz. echocardiography is a study similar in idea to the stress ECG that utilizes a pharmacologic agent to assess the patient for ischemia or stress-induced valvular abnormalities.Transesophageal echocardiography, on the other hand, is performed using a special endoscope with an ultrasound probe mounted on its end that is introduced orally into the esophagus under sedation. Posterior structures such as the mitral valve and left atrium are particularly well visualized. TEEs are frequently used intraoperatively during cardiothoracic surgery to assess global cardiac function, integrity of valve repairs and replace-ments, intracavitary thrombus and/or air, and aortic athero-sclerosis or dissections that can have significant influences on operative strategy.Brunicardi_Ch21_p0801-p0852.indd 80401/03/19 5:32 PM 805ACQUIRED HEART DISEASECHAPTER 21Figure 21-1. Stepwise approach to perioperative cardiac assessment for coronary artery disease. (Reproduced with permission from Fleisher LA, |
Surgery_Schwartz_5361 | Surgery_Schwartz | 80401/03/19 5:32 PM 805ACQUIRED HEART DISEASECHAPTER 21Figure 21-1. Stepwise approach to perioperative cardiac assessment for coronary artery disease. (Reproduced with permission from Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Circulation. 2014 Dec 9;130(24):2215-2245.)EmergencyACS†(Step 2)YesYesNoNoModerate or greater(˜4 METs) functionalcapacityPoor OR unknownfunctional capacity(<4 METs):Will further testing impactdecision making ORperioperative care?(Step 6)No orunknownPatient scheduled for surgery withknown or risk factors for CAD*(Step 1)Clinical risk stratiÿcationand proceed to surgeryEvaluate and treataccording to GDMT†Estimated perioperative risk of MACEbased on combined clinical/surgical risk(Step 3)Low risk (<1%)(Step | Surgery_Schwartz. 80401/03/19 5:32 PM 805ACQUIRED HEART DISEASECHAPTER 21Figure 21-1. Stepwise approach to perioperative cardiac assessment for coronary artery disease. (Reproduced with permission from Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Circulation. 2014 Dec 9;130(24):2215-2245.)EmergencyACS†(Step 2)YesYesNoNoModerate or greater(˜4 METs) functionalcapacityPoor OR unknownfunctional capacity(<4 METs):Will further testing impactdecision making ORperioperative care?(Step 6)No orunknownPatient scheduled for surgery withknown or risk factors for CAD*(Step 1)Clinical risk stratiÿcationand proceed to surgeryEvaluate and treataccording to GDMT†Estimated perioperative risk of MACEbased on combined clinical/surgical risk(Step 3)Low risk (<1%)(Step |
Surgery_Schwartz_5362 | Surgery_Schwartz | 1)Clinical risk stratiÿcationand proceed to surgeryEvaluate and treataccording to GDMT†Estimated perioperative risk of MACEbased on combined clinical/surgical risk(Step 3)Low risk (<1%)(Step 4)Proceed tosurgeryElevated risk(Step 5)No furthertesting(Class III:NB)Proceed to surgeryaccording to GDMT ORalternate strategies(noninvasive treatment,palliation)(Step 7)No furthertesting(Class lIa)No furthertesting(Class IIb)Pharmacologicstress testing(Class lIa)Coronaryrevascularizationaccording toexisting CPGs(Class I)Proceed tosurgeryYesIfnormalIfabnormalNoExcellent(>10 METs)Moderate/Good(˜4–10 METs)Brunicardi_Ch21_p0801-p0852.indd 80501/03/19 5:32 PM 806SPECIFIC CONSIDERATIONSPART IIThere are some more recent additions to the echocardio-graphic armamentarium that capitalize on the strengths of ultra-sound imaging. Three-dimensional TEE is playing an increasing role in the preoperative and intraoperative evaluation of patients with valvular heart disease and is especially helpful in | Surgery_Schwartz. 1)Clinical risk stratiÿcationand proceed to surgeryEvaluate and treataccording to GDMT†Estimated perioperative risk of MACEbased on combined clinical/surgical risk(Step 3)Low risk (<1%)(Step 4)Proceed tosurgeryElevated risk(Step 5)No furthertesting(Class III:NB)Proceed to surgeryaccording to GDMT ORalternate strategies(noninvasive treatment,palliation)(Step 7)No furthertesting(Class lIa)No furthertesting(Class IIb)Pharmacologicstress testing(Class lIa)Coronaryrevascularizationaccording toexisting CPGs(Class I)Proceed tosurgeryYesIfnormalIfabnormalNoExcellent(>10 METs)Moderate/Good(˜4–10 METs)Brunicardi_Ch21_p0801-p0852.indd 80501/03/19 5:32 PM 806SPECIFIC CONSIDERATIONSPART IIThere are some more recent additions to the echocardio-graphic armamentarium that capitalize on the strengths of ultra-sound imaging. Three-dimensional TEE is playing an increasing role in the preoperative and intraoperative evaluation of patients with valvular heart disease and is especially helpful in |
Surgery_Schwartz_5363 | Surgery_Schwartz | of ultra-sound imaging. Three-dimensional TEE is playing an increasing role in the preoperative and intraoperative evaluation of patients with valvular heart disease and is especially helpful in percuta-neous mitral intervention. Tissue Doppler imaging is based on principles akin to conventional Doppler echocardiography, but attention is directed to the myocardium itself as opposed to the motion of blood to quantify abnormalities in wall motion. Strain imaging with speckle-tracking echocardiography measures the actual deformation of the myocardium by following inhomoge-neities inherent to the myocardium and is a useful measure of myocardial function.Radionuclide Studies. Although ECGs are useful, inexpen-sive, and safe, baseline abnormalities in the ECG may limit its diagnostic capacity. In particular, ventricular rhythms, bundle-branch blocks, left ventricular hypertrophy, drug effects, and baseline ST-segment depressions can make stress ECGs dif-ficult to interpret for the presence | Surgery_Schwartz. of ultra-sound imaging. Three-dimensional TEE is playing an increasing role in the preoperative and intraoperative evaluation of patients with valvular heart disease and is especially helpful in percuta-neous mitral intervention. Tissue Doppler imaging is based on principles akin to conventional Doppler echocardiography, but attention is directed to the myocardium itself as opposed to the motion of blood to quantify abnormalities in wall motion. Strain imaging with speckle-tracking echocardiography measures the actual deformation of the myocardium by following inhomoge-neities inherent to the myocardium and is a useful measure of myocardial function.Radionuclide Studies. Although ECGs are useful, inexpen-sive, and safe, baseline abnormalities in the ECG may limit its diagnostic capacity. In particular, ventricular rhythms, bundle-branch blocks, left ventricular hypertrophy, drug effects, and baseline ST-segment depressions can make stress ECGs dif-ficult to interpret for the presence |
Surgery_Schwartz_5364 | Surgery_Schwartz | In particular, ventricular rhythms, bundle-branch blocks, left ventricular hypertrophy, drug effects, and baseline ST-segment depressions can make stress ECGs dif-ficult to interpret for the presence of myocardial ischemia. In this setting, myocardial perfusion imaging (MPI) using radionu-clides can be utilized. Thallium 201 (201Tl) was the initial radio-nuclide used for MPI, but due to its long half-life and relatively low photopeak, it has largely been replaced by technetium-99m (sestamibi and tetrofosmin) because of its more favorable char-acteristics. In the past, planar imaging with three separate 2D views of the heart were obtained. Currently, it is more common to have the images acquired by single-photon emission com-puted tomography (SPECT) technology, which detects emit-ted photons from 180° to 360° around the patient. The signals are then processed to reconstruct multiple slices that together provide a 3D image. The distribution of radionuclides depends on perfusion, and | Surgery_Schwartz. In particular, ventricular rhythms, bundle-branch blocks, left ventricular hypertrophy, drug effects, and baseline ST-segment depressions can make stress ECGs dif-ficult to interpret for the presence of myocardial ischemia. In this setting, myocardial perfusion imaging (MPI) using radionu-clides can be utilized. Thallium 201 (201Tl) was the initial radio-nuclide used for MPI, but due to its long half-life and relatively low photopeak, it has largely been replaced by technetium-99m (sestamibi and tetrofosmin) because of its more favorable char-acteristics. In the past, planar imaging with three separate 2D views of the heart were obtained. Currently, it is more common to have the images acquired by single-photon emission com-puted tomography (SPECT) technology, which detects emit-ted photons from 180° to 360° around the patient. The signals are then processed to reconstruct multiple slices that together provide a 3D image. The distribution of radionuclides depends on perfusion, and |
Surgery_Schwartz_5365 | Surgery_Schwartz | from 180° to 360° around the patient. The signals are then processed to reconstruct multiple slices that together provide a 3D image. The distribution of radionuclides depends on perfusion, and therefore areas that show uptake at rest, but not during stress, are concerning for ischemia. The amount of uptake at both rest and stressed states is compared to assess ischemia and viability of the myocardium. Territories that do not show uptake at rest or during stress are likely to be nonvi-able scar. The sensitivity and specificity of exercise SPECT are 87% and 73%, respectively.8,9The image acquisition may also be gated to a simultane-ously obtained ECG to assess global ventricular function. The endocardial and epicardial borders (as delineated by radionu-clide uptake) are detected throughout the cardiac cycle and the ejection fraction, along with end-systolic and end-diastolic vol-umes, can be calculated. This study is also useful in revealing hypokinetic segments of the myocardium.One | Surgery_Schwartz. from 180° to 360° around the patient. The signals are then processed to reconstruct multiple slices that together provide a 3D image. The distribution of radionuclides depends on perfusion, and therefore areas that show uptake at rest, but not during stress, are concerning for ischemia. The amount of uptake at both rest and stressed states is compared to assess ischemia and viability of the myocardium. Territories that do not show uptake at rest or during stress are likely to be nonvi-able scar. The sensitivity and specificity of exercise SPECT are 87% and 73%, respectively.8,9The image acquisition may also be gated to a simultane-ously obtained ECG to assess global ventricular function. The endocardial and epicardial borders (as delineated by radionu-clide uptake) are detected throughout the cardiac cycle and the ejection fraction, along with end-systolic and end-diastolic vol-umes, can be calculated. This study is also useful in revealing hypokinetic segments of the myocardium.One |
Surgery_Schwartz_5366 | Surgery_Schwartz | the cardiac cycle and the ejection fraction, along with end-systolic and end-diastolic vol-umes, can be calculated. This study is also useful in revealing hypokinetic segments of the myocardium.One significant drawback of SPECT imaging is that it shows regional ischemia well, but it does not adequately detect global or “balanced” ischemia that can occur with diffuse CAD. Positron emission tomography (PET) has been used due to its ability to obtain absolute quantitative data on both myocardial perfusion and metabolism. Tracers used in PET scans can be divided into those that assess perfusion (oxygen-15, nitrogen-13, and rubidiuim-82) and those that assess metabolism (carbon-11 and fluorine-18). The specificity of PET in detecting CAD is better than SPECT at 86% due to its superior spatial resolution.10Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) has a wide variety of uses in cardiac imaging depending on the pulse sequence and signal weighting. Cine-loop imaging of the | Surgery_Schwartz. the cardiac cycle and the ejection fraction, along with end-systolic and end-diastolic vol-umes, can be calculated. This study is also useful in revealing hypokinetic segments of the myocardium.One significant drawback of SPECT imaging is that it shows regional ischemia well, but it does not adequately detect global or “balanced” ischemia that can occur with diffuse CAD. Positron emission tomography (PET) has been used due to its ability to obtain absolute quantitative data on both myocardial perfusion and metabolism. Tracers used in PET scans can be divided into those that assess perfusion (oxygen-15, nitrogen-13, and rubidiuim-82) and those that assess metabolism (carbon-11 and fluorine-18). The specificity of PET in detecting CAD is better than SPECT at 86% due to its superior spatial resolution.10Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) has a wide variety of uses in cardiac imaging depending on the pulse sequence and signal weighting. Cine-loop imaging of the |
Surgery_Schwartz_5367 | Surgery_Schwartz | resolution.10Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) has a wide variety of uses in cardiac imaging depending on the pulse sequence and signal weighting. Cine-loop imaging of the heart throughout the cardiac cycle can yield information on global chamber function, geometry, and valvular pathologies. The differential response of normal and ischemic myocardium to certain pulse sequences allows imaging of myocardial per-fusion using MRI. Use of contrast agents such as gadolinium can enhance scar tissue and are very useful in viability assess-ment. Myocardial strain imaging can also be performed taking advantage of radio-frequency tagging of the myocardium, which deforms with the tissue and can be followed throughout the car-diac cycle.Cardiac Catheterization. Cardiac catheterization involves access to the cardiac chambers, coronary arteries, and great vessels with a peripherally inserted catheter under fluoroscopic guidance. It is a versatile tool used to investigate | Surgery_Schwartz. resolution.10Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) has a wide variety of uses in cardiac imaging depending on the pulse sequence and signal weighting. Cine-loop imaging of the heart throughout the cardiac cycle can yield information on global chamber function, geometry, and valvular pathologies. The differential response of normal and ischemic myocardium to certain pulse sequences allows imaging of myocardial per-fusion using MRI. Use of contrast agents such as gadolinium can enhance scar tissue and are very useful in viability assess-ment. Myocardial strain imaging can also be performed taking advantage of radio-frequency tagging of the myocardium, which deforms with the tissue and can be followed throughout the car-diac cycle.Cardiac Catheterization. Cardiac catheterization involves access to the cardiac chambers, coronary arteries, and great vessels with a peripherally inserted catheter under fluoroscopic guidance. It is a versatile tool used to investigate |
Surgery_Schwartz_5368 | Surgery_Schwartz | involves access to the cardiac chambers, coronary arteries, and great vessels with a peripherally inserted catheter under fluoroscopic guidance. It is a versatile tool used to investigate cardiac cham-ber pressures, valvular abnormalities, wall motion, and coronary artery anatomy. While some of these roles are being replaced by less invasive techniques mentioned previously, cardiac cath-eterization continues to be widely performed and is the gold standard for the assessment of coronary artery disease.11Left heart catheterization is performed by percutaneous access of the femoral, or radial, artery. Under fluoroscopic guid-ance, the catheter is threaded into the ascending aorta where a contrast aortogram may be performed. Coronary angiography requires manipulation of this catheter into the coronary ostia where contrast is directly injected. With advancement of the catheter retrograde through the aortic valve, left ventricular pressures can be obtained. This measurement is used to | Surgery_Schwartz. involves access to the cardiac chambers, coronary arteries, and great vessels with a peripherally inserted catheter under fluoroscopic guidance. It is a versatile tool used to investigate cardiac cham-ber pressures, valvular abnormalities, wall motion, and coronary artery anatomy. While some of these roles are being replaced by less invasive techniques mentioned previously, cardiac cath-eterization continues to be widely performed and is the gold standard for the assessment of coronary artery disease.11Left heart catheterization is performed by percutaneous access of the femoral, or radial, artery. Under fluoroscopic guid-ance, the catheter is threaded into the ascending aorta where a contrast aortogram may be performed. Coronary angiography requires manipulation of this catheter into the coronary ostia where contrast is directly injected. With advancement of the catheter retrograde through the aortic valve, left ventricular pressures can be obtained. This measurement is used to |
Surgery_Schwartz_5369 | Surgery_Schwartz | the coronary ostia where contrast is directly injected. With advancement of the catheter retrograde through the aortic valve, left ventricular pressures can be obtained. This measurement is used to calcu-late direct pressure gradients across the aortic valve, in con-trast to echocardiography that indirectly measures pressure, and can be used to confirm severe aortic stenosis. Again, contrast injection into the left ventricle can be used to estimate ejection fraction and visualize hypokinetic segments of the myocardium. Inappropriate retrograde leakage of contrast may indicate insuf-ficiency of the aortic and/or mitral valves.Coronary angiography provides information on hemody-namically significant stenoses in the coronary circulation as well as an anatomical roadmap for surgeons to plan revascularization (Fig. 21-2A,B). A stenosis is considered to be significant if it narrows the lumen of the artery by 70% (or 50% in the case of left main coronary artery). Borderline lesions or | Surgery_Schwartz. the coronary ostia where contrast is directly injected. With advancement of the catheter retrograde through the aortic valve, left ventricular pressures can be obtained. This measurement is used to calcu-late direct pressure gradients across the aortic valve, in con-trast to echocardiography that indirectly measures pressure, and can be used to confirm severe aortic stenosis. Again, contrast injection into the left ventricle can be used to estimate ejection fraction and visualize hypokinetic segments of the myocardium. Inappropriate retrograde leakage of contrast may indicate insuf-ficiency of the aortic and/or mitral valves.Coronary angiography provides information on hemody-namically significant stenoses in the coronary circulation as well as an anatomical roadmap for surgeons to plan revascularization (Fig. 21-2A,B). A stenosis is considered to be significant if it narrows the lumen of the artery by 70% (or 50% in the case of left main coronary artery). Borderline lesions or |
Surgery_Schwartz_5370 | Surgery_Schwartz | plan revascularization (Fig. 21-2A,B). A stenosis is considered to be significant if it narrows the lumen of the artery by 70% (or 50% in the case of left main coronary artery). Borderline lesions or complex lesions may be assessed by fractional flow reserve (FFR) or instant wave-free radio (iFR), which obviates the need of adenosine.12 This has been shown to very helpful in guiding revasculariza-tion strategies in recent clinical trials.13 Additional assessment can also be done using intravascular ultrasound (IVUS) inside the coronary circulation. There is some variability in the coro-nary arterial anatomy with the posterior descending artery being supplied by the right coronary artery in approximately 80% of patients (right dominant) or the left coronary artery in approxi-mately 15% of patients (left dominant). The remaining patients have a codominant circulation where the posterior descending artery is supplied by both the right and left coronaries.Right heart catheterization is | Surgery_Schwartz. plan revascularization (Fig. 21-2A,B). A stenosis is considered to be significant if it narrows the lumen of the artery by 70% (or 50% in the case of left main coronary artery). Borderline lesions or complex lesions may be assessed by fractional flow reserve (FFR) or instant wave-free radio (iFR), which obviates the need of adenosine.12 This has been shown to very helpful in guiding revasculariza-tion strategies in recent clinical trials.13 Additional assessment can also be done using intravascular ultrasound (IVUS) inside the coronary circulation. There is some variability in the coro-nary arterial anatomy with the posterior descending artery being supplied by the right coronary artery in approximately 80% of patients (right dominant) or the left coronary artery in approxi-mately 15% of patients (left dominant). The remaining patients have a codominant circulation where the posterior descending artery is supplied by both the right and left coronaries.Right heart catheterization is |
Surgery_Schwartz_5371 | Surgery_Schwartz | patients (left dominant). The remaining patients have a codominant circulation where the posterior descending artery is supplied by both the right and left coronaries.Right heart catheterization is performed by the introduc-tion of catheter through a peripheral vein that is advanced into the right side of the heart.14 Right-sided pressures and structures are assessed in a similar fashion as in the left heart. Extension of the catheter into the pulmonary artery allows measurement of pulmonary artery pressures as well as pulmonary capillary wedge pressure (reflecting left ventricular end diastolic pres-sure) with an occlusive balloon. In addition to these measure-ments, cardiac output can be measured using thermodilution or by the Fick method using oxygen saturations of blood sampled from the various locations during the procedure.Brunicardi_Ch21_p0801-p0852.indd 80601/03/19 5:32 PM 807ACQUIRED HEART DISEASECHAPTER 21Figure 21-2. Cardiac catheterization angiography. A. Stenosis of | Surgery_Schwartz. patients (left dominant). The remaining patients have a codominant circulation where the posterior descending artery is supplied by both the right and left coronaries.Right heart catheterization is performed by the introduc-tion of catheter through a peripheral vein that is advanced into the right side of the heart.14 Right-sided pressures and structures are assessed in a similar fashion as in the left heart. Extension of the catheter into the pulmonary artery allows measurement of pulmonary artery pressures as well as pulmonary capillary wedge pressure (reflecting left ventricular end diastolic pres-sure) with an occlusive balloon. In addition to these measure-ments, cardiac output can be measured using thermodilution or by the Fick method using oxygen saturations of blood sampled from the various locations during the procedure.Brunicardi_Ch21_p0801-p0852.indd 80601/03/19 5:32 PM 807ACQUIRED HEART DISEASECHAPTER 21Figure 21-2. Cardiac catheterization angiography. A. Stenosis of |
Surgery_Schwartz_5372 | Surgery_Schwartz | the various locations during the procedure.Brunicardi_Ch21_p0801-p0852.indd 80601/03/19 5:32 PM 807ACQUIRED HEART DISEASECHAPTER 21Figure 21-2. Cardiac catheterization angiography. A. Stenosis of right coronary artery indicated by the arrow. B. Still image of a normal left ventriculogram.ABAn advantage of cardiac catheterization is that it offers an opportunity for interventional therapy of coronary artery disease, arrhythmias, valvular abnormalities, and other struc-tural defects of the heart. Cardiac catheterization is generally safe, but being an invasive procedure, it is associated with rare complications. The overall mortality is 0.11%, and total rate of major complications, including MI, stroke, arrhythmia, vascular injury, contrast reaction including allergic reaction and contrast-induced nephropathy, hemodynamic instability, and cardiac per-foration is usually <2%.15Cardiac Computed Tomography. Multislice computed tomography (CT) imaging can be used to assess the coronary | Surgery_Schwartz. the various locations during the procedure.Brunicardi_Ch21_p0801-p0852.indd 80601/03/19 5:32 PM 807ACQUIRED HEART DISEASECHAPTER 21Figure 21-2. Cardiac catheterization angiography. A. Stenosis of right coronary artery indicated by the arrow. B. Still image of a normal left ventriculogram.ABAn advantage of cardiac catheterization is that it offers an opportunity for interventional therapy of coronary artery disease, arrhythmias, valvular abnormalities, and other struc-tural defects of the heart. Cardiac catheterization is generally safe, but being an invasive procedure, it is associated with rare complications. The overall mortality is 0.11%, and total rate of major complications, including MI, stroke, arrhythmia, vascular injury, contrast reaction including allergic reaction and contrast-induced nephropathy, hemodynamic instability, and cardiac per-foration is usually <2%.15Cardiac Computed Tomography. Multislice computed tomography (CT) imaging can be used to assess the coronary |
Surgery_Schwartz_5373 | Surgery_Schwartz | nephropathy, hemodynamic instability, and cardiac per-foration is usually <2%.15Cardiac Computed Tomography. Multislice computed tomography (CT) imaging can be used to assess the coronary vasculature. The coronary calcium score is an index devel-oped to quantify the degree of coronary atherosclerotic burden by measuring Hounsfield units in a noncontrast cardiac CT. Although this technique is quite sensitive for angiographic stenoses (>50%) it remains fairly nonspecific as calcification often precedes significant luminal narrowing.16 CT coronary angiography using intravenous contrast is also utilized clini-cally to assess coronary pathology and is particularly useful in the emergency room to perform a “triple rule-out” for acute coronary events, pulmonary embolism, and aortic dissection in patients who present with undifferentiated chest pain. LV ejec-tion fraction may be measured by this technique, and, together with the degree of coronary stenosis, it has been shown to have | Surgery_Schwartz. nephropathy, hemodynamic instability, and cardiac per-foration is usually <2%.15Cardiac Computed Tomography. Multislice computed tomography (CT) imaging can be used to assess the coronary vasculature. The coronary calcium score is an index devel-oped to quantify the degree of coronary atherosclerotic burden by measuring Hounsfield units in a noncontrast cardiac CT. Although this technique is quite sensitive for angiographic stenoses (>50%) it remains fairly nonspecific as calcification often precedes significant luminal narrowing.16 CT coronary angiography using intravenous contrast is also utilized clini-cally to assess coronary pathology and is particularly useful in the emergency room to perform a “triple rule-out” for acute coronary events, pulmonary embolism, and aortic dissection in patients who present with undifferentiated chest pain. LV ejec-tion fraction may be measured by this technique, and, together with the degree of coronary stenosis, it has been shown to have |
Surgery_Schwartz_5374 | Surgery_Schwartz | in patients who present with undifferentiated chest pain. LV ejec-tion fraction may be measured by this technique, and, together with the degree of coronary stenosis, it has been shown to have incremental prognostic value for the presence of coronary artery disease and in the prediction of adverse coronary events.17EXTRACORPOREAL PERFUSIONHistoryPrior to the development of extracorporeal perfusion, heart sur-gery was rarely performed and was limited to brief periods of asystole and/or hypothermia. The need for obtaining a bloodless operating field, while maintaining perfusion of heart and other organs, was evident.John Gibbon’s motivation to develop a means for extra-corporeal perfusion came from a desire to safely open the pulmonary artery in a patient who suffered from a pulmonary embolus following a cholecystectomy. After numerous experi-mental iterations, Gibbon’s cardiopulmonary bypass machine was first used clinically in 1953 to repair an atrial septal defect in an 18-year-old | Surgery_Schwartz. in patients who present with undifferentiated chest pain. LV ejec-tion fraction may be measured by this technique, and, together with the degree of coronary stenosis, it has been shown to have incremental prognostic value for the presence of coronary artery disease and in the prediction of adverse coronary events.17EXTRACORPOREAL PERFUSIONHistoryPrior to the development of extracorporeal perfusion, heart sur-gery was rarely performed and was limited to brief periods of asystole and/or hypothermia. The need for obtaining a bloodless operating field, while maintaining perfusion of heart and other organs, was evident.John Gibbon’s motivation to develop a means for extra-corporeal perfusion came from a desire to safely open the pulmonary artery in a patient who suffered from a pulmonary embolus following a cholecystectomy. After numerous experi-mental iterations, Gibbon’s cardiopulmonary bypass machine was first used clinically in 1953 to repair an atrial septal defect in an 18-year-old |
Surgery_Schwartz_5375 | Surgery_Schwartz | following a cholecystectomy. After numerous experi-mental iterations, Gibbon’s cardiopulmonary bypass machine was first used clinically in 1953 to repair an atrial septal defect in an 18-year-old woman.18 Although Gibbon is credited for its invention, the development of modern cardiopulmonary bypass (CPB) is a culmination of the work of many investi-gators throughout the world. The early bubble oxygenators have evolved into the currently used membrane oxygenators. The search for an ideal biocompatible material that minimizes the inflammatory cascade initiated by the contact of blood with the circuit components continues to this day.TechniqueThe basic CPB circuit consists of the venous cannulae, a venous reservoir, pump, oxygenator, filter, and the arterial cannula.Anticoagulation is required during CPB, and 300 to 400 units/kg of heparin are given to increase the activated clotting time (ACT) to greater than 450 seconds. Once an ade-quate level of anticoagulation is achieved, | Surgery_Schwartz. following a cholecystectomy. After numerous experi-mental iterations, Gibbon’s cardiopulmonary bypass machine was first used clinically in 1953 to repair an atrial septal defect in an 18-year-old woman.18 Although Gibbon is credited for its invention, the development of modern cardiopulmonary bypass (CPB) is a culmination of the work of many investi-gators throughout the world. The early bubble oxygenators have evolved into the currently used membrane oxygenators. The search for an ideal biocompatible material that minimizes the inflammatory cascade initiated by the contact of blood with the circuit components continues to this day.TechniqueThe basic CPB circuit consists of the venous cannulae, a venous reservoir, pump, oxygenator, filter, and the arterial cannula.Anticoagulation is required during CPB, and 300 to 400 units/kg of heparin are given to increase the activated clotting time (ACT) to greater than 450 seconds. Once an ade-quate level of anticoagulation is achieved, |
Surgery_Schwartz_5376 | Surgery_Schwartz | required during CPB, and 300 to 400 units/kg of heparin are given to increase the activated clotting time (ACT) to greater than 450 seconds. Once an ade-quate level of anticoagulation is achieved, arterial cannulation is performed through a purse-string suture or through a side graft sewn onto the native artery. The distal ascending thoracic aorta is the most common site of cannulation. Other routinely utilized sites of cannulation include the femoral artery, the axillary artery, the innominate artery, or the distal aortic arch, and they are altered based on the indicated surgical repair and the pres-ence of native arterial disease. Venous cannulation is performed through purse-string sutures placed on the right atrium either for a single cannula or for two separate cannulae placed into the superior and inferior vena cava, respectively. Alternatively, the venous cannula may be inserted from the femoral vein and advanced into the right atrium and superior vena cava using TEE guidance. | Surgery_Schwartz. required during CPB, and 300 to 400 units/kg of heparin are given to increase the activated clotting time (ACT) to greater than 450 seconds. Once an ade-quate level of anticoagulation is achieved, arterial cannulation is performed through a purse-string suture or through a side graft sewn onto the native artery. The distal ascending thoracic aorta is the most common site of cannulation. Other routinely utilized sites of cannulation include the femoral artery, the axillary artery, the innominate artery, or the distal aortic arch, and they are altered based on the indicated surgical repair and the pres-ence of native arterial disease. Venous cannulation is performed through purse-string sutures placed on the right atrium either for a single cannula or for two separate cannulae placed into the superior and inferior vena cava, respectively. Alternatively, the venous cannula may be inserted from the femoral vein and advanced into the right atrium and superior vena cava using TEE guidance. |
Surgery_Schwartz_5377 | Surgery_Schwartz | superior and inferior vena cava, respectively. Alternatively, the venous cannula may be inserted from the femoral vein and advanced into the right atrium and superior vena cava using TEE guidance. This technique is frequently used in minimally invasive cardiac surgery.Effective communication between the surgeon, the anes-thesiologist, and the perfusionist is mandatory for effective Brunicardi_Ch21_p0801-p0852.indd 80701/03/19 5:32 PM 808SPECIFIC CONSIDERATIONSPART IIcardiopulmonary bypass. Once the appropriate cannulations and connections are complete, CPB is commenced. Venous return is initiated followed by arterial flow while monitoring systemic blood pressure. At normothermia, the flow required is approxi-mately 2.4 L/min/m2, but with hypothermia, oxygen consump-tion is reduced by 50% for every 10°C drop in temperature, and a flow of only 1 L/min/m2 is required at 18°C. Once the heart is decompressed and hemodynamics are acceptable, ventilation is stopped. The oxygenator is | Surgery_Schwartz. superior and inferior vena cava, respectively. Alternatively, the venous cannula may be inserted from the femoral vein and advanced into the right atrium and superior vena cava using TEE guidance. This technique is frequently used in minimally invasive cardiac surgery.Effective communication between the surgeon, the anes-thesiologist, and the perfusionist is mandatory for effective Brunicardi_Ch21_p0801-p0852.indd 80701/03/19 5:32 PM 808SPECIFIC CONSIDERATIONSPART IIcardiopulmonary bypass. Once the appropriate cannulations and connections are complete, CPB is commenced. Venous return is initiated followed by arterial flow while monitoring systemic blood pressure. At normothermia, the flow required is approxi-mately 2.4 L/min/m2, but with hypothermia, oxygen consump-tion is reduced by 50% for every 10°C drop in temperature, and a flow of only 1 L/min/m2 is required at 18°C. Once the heart is decompressed and hemodynamics are acceptable, ventilation is stopped. The oxygenator is |
Surgery_Schwartz_5378 | Surgery_Schwartz | by 50% for every 10°C drop in temperature, and a flow of only 1 L/min/m2 is required at 18°C. Once the heart is decompressed and hemodynamics are acceptable, ventilation is stopped. The oxygenator is adjusted to maintain a Pao2 of 150 mmHg and normocarbia. Blood can also be filtered and returned through vents that are placed in chambers of the heart (such as the left ventricle or pulmonary artery) or through the cardiotomy suction used to aspirate blood from the surgical field. When the cardiac procedure is complete, the patient is rewarmed, the lungs ventilated, and the heart defibrillated, if needed. The venous return to the CPB machine is gradually reduced allowing the heart to fill. The pump is also slowed while hemodynamics and global cardiac function are assessed with a TEE probe. Ino-tropic and vasopressor support may be used to augment cardiac function and treat hypotension. Once CPB has been weaned and stable hemodynamics achieved, the cannulae are removed. The heparin | Surgery_Schwartz. by 50% for every 10°C drop in temperature, and a flow of only 1 L/min/m2 is required at 18°C. Once the heart is decompressed and hemodynamics are acceptable, ventilation is stopped. The oxygenator is adjusted to maintain a Pao2 of 150 mmHg and normocarbia. Blood can also be filtered and returned through vents that are placed in chambers of the heart (such as the left ventricle or pulmonary artery) or through the cardiotomy suction used to aspirate blood from the surgical field. When the cardiac procedure is complete, the patient is rewarmed, the lungs ventilated, and the heart defibrillated, if needed. The venous return to the CPB machine is gradually reduced allowing the heart to fill. The pump is also slowed while hemodynamics and global cardiac function are assessed with a TEE probe. Ino-tropic and vasopressor support may be used to augment cardiac function and treat hypotension. Once CPB has been weaned and stable hemodynamics achieved, the cannulae are removed. The heparin |
Surgery_Schwartz_5379 | Surgery_Schwartz | Ino-tropic and vasopressor support may be used to augment cardiac function and treat hypotension. Once CPB has been weaned and stable hemodynamics achieved, the cannulae are removed. The heparin anticoagulation is reversed with 1 mg protamine per 100 units of heparin and hemostasis is achieved.19Adverse EffectsCardiopulmonary bypass has a number of deleterious effects as various intertwining processes result in derangements in hemo-stasis, an enhanced systemic inflammatory response, and end-organ function.Anticoagulation prior to the commencement of CPB is required as contact of blood with the artificial surfaces of the cir-cuit can initiate a thrombogenic cascade. Generation of thrombin plays a major role in both thrombotic and bleeding phenomena during CPB. The endothelium that normally regulates the fine balance between procoagulant and anticoagulant pathways is perturbed. Fibrinogen is consumed rapidly as thrombin converts fibrinogen to fibrin while fibrinolytic mechanisms | Surgery_Schwartz. Ino-tropic and vasopressor support may be used to augment cardiac function and treat hypotension. Once CPB has been weaned and stable hemodynamics achieved, the cannulae are removed. The heparin anticoagulation is reversed with 1 mg protamine per 100 units of heparin and hemostasis is achieved.19Adverse EffectsCardiopulmonary bypass has a number of deleterious effects as various intertwining processes result in derangements in hemo-stasis, an enhanced systemic inflammatory response, and end-organ function.Anticoagulation prior to the commencement of CPB is required as contact of blood with the artificial surfaces of the cir-cuit can initiate a thrombogenic cascade. Generation of thrombin plays a major role in both thrombotic and bleeding phenomena during CPB. The endothelium that normally regulates the fine balance between procoagulant and anticoagulant pathways is perturbed. Fibrinogen is consumed rapidly as thrombin converts fibrinogen to fibrin while fibrinolytic mechanisms |
Surgery_Schwartz_5380 | Surgery_Schwartz | regulates the fine balance between procoagulant and anticoagulant pathways is perturbed. Fibrinogen is consumed rapidly as thrombin converts fibrinogen to fibrin while fibrinolytic mechanisms (initiated by the activated endothelium) degrade the fibrin macromolecules. Platelets are activated by the converging hemostatic pathways and are consumed.The response of the humoral and cellular immune systems partly overlap with the hemostatic pathways. The classic and alternative complement pathways are activated by CPB gen-erating powerful chemotaxic molecules and anaphylatoxins.20 Monocytes, platelets, and neutrophils are activated releasing acute inflammatory mediators and cytokines that persist even after conclusion of CPB.21 These inflammatory cells also pro-duce reactive oxidants that may have cytotoxic and cardiovas-cular effects such as vasodilation and hypotension.The large quantity of unfractionated heparin used during cardiac surgery predisposes patients to developing | Surgery_Schwartz. regulates the fine balance between procoagulant and anticoagulant pathways is perturbed. Fibrinogen is consumed rapidly as thrombin converts fibrinogen to fibrin while fibrinolytic mechanisms (initiated by the activated endothelium) degrade the fibrin macromolecules. Platelets are activated by the converging hemostatic pathways and are consumed.The response of the humoral and cellular immune systems partly overlap with the hemostatic pathways. The classic and alternative complement pathways are activated by CPB gen-erating powerful chemotaxic molecules and anaphylatoxins.20 Monocytes, platelets, and neutrophils are activated releasing acute inflammatory mediators and cytokines that persist even after conclusion of CPB.21 These inflammatory cells also pro-duce reactive oxidants that may have cytotoxic and cardiovas-cular effects such as vasodilation and hypotension.The large quantity of unfractionated heparin used during cardiac surgery predisposes patients to developing |
Surgery_Schwartz_5381 | Surgery_Schwartz | that may have cytotoxic and cardiovas-cular effects such as vasodilation and hypotension.The large quantity of unfractionated heparin used during cardiac surgery predisposes patients to developing heparin-induced thrombocytopenia (HIT) with an incidence of 1% to 5%.22 Platelet factor-4 (PF4) is produced by platelets and avidly binds to heparin to form a heparin-PF4 complex that can be antigenic in some patients binding IgG. The IgG-heparin-PF4 complex can bind to platelets, which causes release of more PF4, perpetuating the process. The earliest sign is a sudden drop of more than 50% in the platelet count, usually seen from sev-eral hours to days after surgery. HIT can be confirmed with an enzyme-linked immunosorbent assay (ELISA) or serotonin release assay (SRA). Of the patients with HIT, 20% to 50% of patients develop thromboses in arterial or venous beds, designated as heparin-induced thrombocytopenia and thrombo-sis (HITT), which can be life-threatening.23 Treatment is | Surgery_Schwartz. that may have cytotoxic and cardiovas-cular effects such as vasodilation and hypotension.The large quantity of unfractionated heparin used during cardiac surgery predisposes patients to developing heparin-induced thrombocytopenia (HIT) with an incidence of 1% to 5%.22 Platelet factor-4 (PF4) is produced by platelets and avidly binds to heparin to form a heparin-PF4 complex that can be antigenic in some patients binding IgG. The IgG-heparin-PF4 complex can bind to platelets, which causes release of more PF4, perpetuating the process. The earliest sign is a sudden drop of more than 50% in the platelet count, usually seen from sev-eral hours to days after surgery. HIT can be confirmed with an enzyme-linked immunosorbent assay (ELISA) or serotonin release assay (SRA). Of the patients with HIT, 20% to 50% of patients develop thromboses in arterial or venous beds, designated as heparin-induced thrombocytopenia and thrombo-sis (HITT), which can be life-threatening.23 Treatment is |
Surgery_Schwartz_5382 | Surgery_Schwartz | with HIT, 20% to 50% of patients develop thromboses in arterial or venous beds, designated as heparin-induced thrombocytopenia and thrombo-sis (HITT), which can be life-threatening.23 Treatment is anti-coagulation with nonheparin anticoagulant (e.g., argatroban, bivalirudin).The etiology of end-organ dysfunction resulting from extracorporeal circulation can mostly be categorized into one of three mechanisms: hypoperfusion, embolization, and whole-body inflammatory response. Although cardiac output and blood pressure are monitored carefully during CPB, they are surrogates for regional perfusion and cannot detect end-organ hypoperfusion directly. This can be a problem particularly with the cerebral, renal, and mesenteric circulations. With manip-ulation of diseased vessels and dysregulation of the native coagulation system, macroscopic and microscopic emboli are a concern. Activated cells and circulating cytotoxic products of the immune response may cause microvascular injury and edema | Surgery_Schwartz. with HIT, 20% to 50% of patients develop thromboses in arterial or venous beds, designated as heparin-induced thrombocytopenia and thrombo-sis (HITT), which can be life-threatening.23 Treatment is anti-coagulation with nonheparin anticoagulant (e.g., argatroban, bivalirudin).The etiology of end-organ dysfunction resulting from extracorporeal circulation can mostly be categorized into one of three mechanisms: hypoperfusion, embolization, and whole-body inflammatory response. Although cardiac output and blood pressure are monitored carefully during CPB, they are surrogates for regional perfusion and cannot detect end-organ hypoperfusion directly. This can be a problem particularly with the cerebral, renal, and mesenteric circulations. With manip-ulation of diseased vessels and dysregulation of the native coagulation system, macroscopic and microscopic emboli are a concern. Activated cells and circulating cytotoxic products of the immune response may cause microvascular injury and edema |
Surgery_Schwartz_5383 | Surgery_Schwartz | of the native coagulation system, macroscopic and microscopic emboli are a concern. Activated cells and circulating cytotoxic products of the immune response may cause microvascular injury and edema of other organs manifesting as neurocognitive deficits, respiratory failure, and renal injury.24Myocardial ProtectionDuring CPB, pharmacologic agents in cardioplegic solutions may be delivered into the coronary circulation to arrest the heart, allowing for a still operating target and improved myocardial protection. The most common cardioplegia consists of potas-sium-rich solutions that can be mixed with autologous blood and are delivered into the coronary circulation.25 Antegrade cardioplegia is delivered into the root of a cross-clamped aorta or directly into the individual coronary ostial using specialized catheters. A retrograde cardioplegia catheter is a balloon-cuffed catheter that is placed through the right atrium into the coro-nary sinus and is used to perfuse the coronary | Surgery_Schwartz. of the native coagulation system, macroscopic and microscopic emboli are a concern. Activated cells and circulating cytotoxic products of the immune response may cause microvascular injury and edema of other organs manifesting as neurocognitive deficits, respiratory failure, and renal injury.24Myocardial ProtectionDuring CPB, pharmacologic agents in cardioplegic solutions may be delivered into the coronary circulation to arrest the heart, allowing for a still operating target and improved myocardial protection. The most common cardioplegia consists of potas-sium-rich solutions that can be mixed with autologous blood and are delivered into the coronary circulation.25 Antegrade cardioplegia is delivered into the root of a cross-clamped aorta or directly into the individual coronary ostial using specialized catheters. A retrograde cardioplegia catheter is a balloon-cuffed catheter that is placed through the right atrium into the coro-nary sinus and is used to perfuse the coronary |
Surgery_Schwartz_5384 | Surgery_Schwartz | using specialized catheters. A retrograde cardioplegia catheter is a balloon-cuffed catheter that is placed through the right atrium into the coro-nary sinus and is used to perfuse the coronary circulation in the opposite direction through the venous circulation. This has the advantage of more uniform distribution in patients with diffuse coronary artery disease and is not dependent on a competent aortic valve for delivery.There is continued debate regarding the best method (ante-grade vs. retrograde vs. both), type (crystalloid vs. blood), tem-perature (cold vs. warm vs. tepid), and interval (continuous vs. intermittent) of cardioplegia delivery. The optimal combination is beyond the scope of this text. However, most cardiac surgeons in the United States favor cold blood potassium cardioplegia.CORONARY ARTERY DISEASEHistoryAortocoronary bypass for myocardial ischemia was first pro-posed and performed in laboratory animals by Carrel in 1910.26 The Vineberg operation, one of the | Surgery_Schwartz. using specialized catheters. A retrograde cardioplegia catheter is a balloon-cuffed catheter that is placed through the right atrium into the coro-nary sinus and is used to perfuse the coronary circulation in the opposite direction through the venous circulation. This has the advantage of more uniform distribution in patients with diffuse coronary artery disease and is not dependent on a competent aortic valve for delivery.There is continued debate regarding the best method (ante-grade vs. retrograde vs. both), type (crystalloid vs. blood), tem-perature (cold vs. warm vs. tepid), and interval (continuous vs. intermittent) of cardioplegia delivery. The optimal combination is beyond the scope of this text. However, most cardiac surgeons in the United States favor cold blood potassium cardioplegia.CORONARY ARTERY DISEASEHistoryAortocoronary bypass for myocardial ischemia was first pro-posed and performed in laboratory animals by Carrel in 1910.26 The Vineberg operation, one of the |
Surgery_Schwartz_5385 | Surgery_Schwartz | cardioplegia.CORONARY ARTERY DISEASEHistoryAortocoronary bypass for myocardial ischemia was first pro-posed and performed in laboratory animals by Carrel in 1910.26 The Vineberg operation, one of the initial attempts at surgical revascularization of the myocardium, was introduced in 1951.27 This procedure involved implantation of the internal thoracic artery directly into the myocardium itself. While some patients were relieved of their anginal symptoms, this resulted in vir-tually no increase in coronary flow and was soon supplanted by methods to restore flow directly. Coronary endarterectomy was introduced by Longmire during this time period but had high rates of restenosis and occlusion.28 The use of vein patches to repair the arteriotomy sites was described by Senning in 1961.29 The first saphenous vein coronary artery bypass grafting (CABG) was performed by Sabiston in 1962,30 but was popular-ized by Favalaro and Sones in 1967.31 In 1968, the internal tho-racic artery was | Surgery_Schwartz. cardioplegia.CORONARY ARTERY DISEASEHistoryAortocoronary bypass for myocardial ischemia was first pro-posed and performed in laboratory animals by Carrel in 1910.26 The Vineberg operation, one of the initial attempts at surgical revascularization of the myocardium, was introduced in 1951.27 This procedure involved implantation of the internal thoracic artery directly into the myocardium itself. While some patients were relieved of their anginal symptoms, this resulted in vir-tually no increase in coronary flow and was soon supplanted by methods to restore flow directly. Coronary endarterectomy was introduced by Longmire during this time period but had high rates of restenosis and occlusion.28 The use of vein patches to repair the arteriotomy sites was described by Senning in 1961.29 The first saphenous vein coronary artery bypass grafting (CABG) was performed by Sabiston in 1962,30 but was popular-ized by Favalaro and Sones in 1967.31 In 1968, the internal tho-racic artery was |
Surgery_Schwartz_5386 | Surgery_Schwartz | The first saphenous vein coronary artery bypass grafting (CABG) was performed by Sabiston in 1962,30 but was popular-ized by Favalaro and Sones in 1967.31 In 1968, the internal tho-racic artery was introduced as a bypass conduit by Green, who used it to bypass the left anterior descending coronary artery.32Brunicardi_Ch21_p0801-p0852.indd 80801/03/19 5:32 PM 809ACQUIRED HEART DISEASECHAPTER 21Etiology and PathogenesisAtherosclerotic stenoses are the primary mechanism of CAD. The pathophysiologic process is initiated with vascular endo-thelial injury and is potentiated by inflammatory mechanisms, circulating lipids, toxins, and other vasoactive agents in the blood. Macrophages and platelets are attracted to this area of endothelial dysfunction inciting a local inflammatory response. During this process, macrophages infiltrate into the intimal lay-ers and accumulate cholesterol-containing low-density lipo-proteins. The growth factors secreted promote proliferation of smooth muscle | Surgery_Schwartz. The first saphenous vein coronary artery bypass grafting (CABG) was performed by Sabiston in 1962,30 but was popular-ized by Favalaro and Sones in 1967.31 In 1968, the internal tho-racic artery was introduced as a bypass conduit by Green, who used it to bypass the left anterior descending coronary artery.32Brunicardi_Ch21_p0801-p0852.indd 80801/03/19 5:32 PM 809ACQUIRED HEART DISEASECHAPTER 21Etiology and PathogenesisAtherosclerotic stenoses are the primary mechanism of CAD. The pathophysiologic process is initiated with vascular endo-thelial injury and is potentiated by inflammatory mechanisms, circulating lipids, toxins, and other vasoactive agents in the blood. Macrophages and platelets are attracted to this area of endothelial dysfunction inciting a local inflammatory response. During this process, macrophages infiltrate into the intimal lay-ers and accumulate cholesterol-containing low-density lipo-proteins. The growth factors secreted promote proliferation of smooth muscle |
Surgery_Schwartz_5387 | Surgery_Schwartz | this process, macrophages infiltrate into the intimal lay-ers and accumulate cholesterol-containing low-density lipo-proteins. The growth factors secreted promote proliferation of smooth muscle cells within the intima and media of the arteries. Together with the accumulation of the lipid-laden macrophages, the smooth muscle hyperplasia results in an atheroma and subse-quent stenosis of the vessel. These atheromas have a fibrous cap that may rupture, exposing the underlying cells and extracellular matrix, which are very prothrombotic. Acute plaque rupture and thrombus formation is thought to be the main pathophysiologic mechanism responsible for acute coronary syndromes.33-35Risk Factors and PreventionPrior to the establishment of modern management strategies, the annual mortality rate from ischemic heart disease was 482 out of 100,000 persons.36 Since the peak of coronary heart dis-ease mortality in 1968, modern primary and secondary preven-tion strategies such as risk factor | Surgery_Schwartz. this process, macrophages infiltrate into the intimal lay-ers and accumulate cholesterol-containing low-density lipo-proteins. The growth factors secreted promote proliferation of smooth muscle cells within the intima and media of the arteries. Together with the accumulation of the lipid-laden macrophages, the smooth muscle hyperplasia results in an atheroma and subse-quent stenosis of the vessel. These atheromas have a fibrous cap that may rupture, exposing the underlying cells and extracellular matrix, which are very prothrombotic. Acute plaque rupture and thrombus formation is thought to be the main pathophysiologic mechanism responsible for acute coronary syndromes.33-35Risk Factors and PreventionPrior to the establishment of modern management strategies, the annual mortality rate from ischemic heart disease was 482 out of 100,000 persons.36 Since the peak of coronary heart dis-ease mortality in 1968, modern primary and secondary preven-tion strategies such as risk factor |
Surgery_Schwartz_5388 | Surgery_Schwartz | rate from ischemic heart disease was 482 out of 100,000 persons.36 Since the peak of coronary heart dis-ease mortality in 1968, modern primary and secondary preven-tion strategies such as risk factor modification, percutaneous and surgical revascularization, use of medications (e.g., aspirin, HMG-CoA reductase inhibitors [statins], and β-blockers), has decreased mortality from coronary artery disease by 74%.36The major risk factors for atherosclerosis include advanced age, cigarette smoking, hypertension, dyslipidemias, sedentary lifestyle, obesity, and diabetes. Likely due to increased public awareness and aggressive medical management, these risk fac-tors (with the exception of glucose intolerance and obesity) have recently been on the decline.Current guidelines outlined in the AHA/ACC consensus statement summarize the secondary prevention recommendations.37 Class I recommendations include smoking cessation and avoid-ance of environmental tobacco exposure, blood pressure con-trol to | Surgery_Schwartz. rate from ischemic heart disease was 482 out of 100,000 persons.36 Since the peak of coronary heart dis-ease mortality in 1968, modern primary and secondary preven-tion strategies such as risk factor modification, percutaneous and surgical revascularization, use of medications (e.g., aspirin, HMG-CoA reductase inhibitors [statins], and β-blockers), has decreased mortality from coronary artery disease by 74%.36The major risk factors for atherosclerosis include advanced age, cigarette smoking, hypertension, dyslipidemias, sedentary lifestyle, obesity, and diabetes. Likely due to increased public awareness and aggressive medical management, these risk fac-tors (with the exception of glucose intolerance and obesity) have recently been on the decline.Current guidelines outlined in the AHA/ACC consensus statement summarize the secondary prevention recommendations.37 Class I recommendations include smoking cessation and avoid-ance of environmental tobacco exposure, blood pressure con-trol to |
Surgery_Schwartz_5389 | Surgery_Schwartz | statement summarize the secondary prevention recommendations.37 Class I recommendations include smoking cessation and avoid-ance of environmental tobacco exposure, blood pressure con-trol to under 140/90 mmHg (under 130/80 mmHg in those with diabetes or chronic kidney disease), LDL cholesterol levels less than 100 mg/dL, aspirin therapy in all patients without contra-indications, a BMI target of less than 25 kg/m2, diabetes man-agement with target HbA1c <7%, and encouragement of daily moderate-intensity aerobic exercise. β-Blockers should be used in all patients with LV dysfunction and following MI, ACS, or revascularization, unless a specific contraindication is pres-ent. Renin-angiogensin-aldosterone system blockade in patients with hypertension, LV dysfunction, diabetes, or chronic kidney disease should also be considered.Clinical ManifestationsPatients with CAD may have a spectrum of presentations, including angina pectoris, myocardial infarction, ischemic heart failure, | Surgery_Schwartz. statement summarize the secondary prevention recommendations.37 Class I recommendations include smoking cessation and avoid-ance of environmental tobacco exposure, blood pressure con-trol to under 140/90 mmHg (under 130/80 mmHg in those with diabetes or chronic kidney disease), LDL cholesterol levels less than 100 mg/dL, aspirin therapy in all patients without contra-indications, a BMI target of less than 25 kg/m2, diabetes man-agement with target HbA1c <7%, and encouragement of daily moderate-intensity aerobic exercise. β-Blockers should be used in all patients with LV dysfunction and following MI, ACS, or revascularization, unless a specific contraindication is pres-ent. Renin-angiogensin-aldosterone system blockade in patients with hypertension, LV dysfunction, diabetes, or chronic kidney disease should also be considered.Clinical ManifestationsPatients with CAD may have a spectrum of presentations, including angina pectoris, myocardial infarction, ischemic heart failure, |
Surgery_Schwartz_5390 | Surgery_Schwartz | kidney disease should also be considered.Clinical ManifestationsPatients with CAD may have a spectrum of presentations, including angina pectoris, myocardial infarction, ischemic heart failure, arrhythmias, and sudden death.Angina pectoris is the pain or discomfort caused by myo-cardial ischemia and is typically substernal and may radiate to the left upper extremity, neck, or epigastrium. The variety of presentations can make myocardial ischemia challenging to diagnose. Characteristics of chest pain that make myocardial ischemia less likely include pleuritic chest pain, pain reproduc-ible by movement or palpation, or brief episodes lasting only seconds. Typical angina is relieved by rest and/or use of sub-lingual nitroglycerin. Differential diagnoses to be considered include, but are not limited to, musculoskeletal pain, pulmonary disorders, esophageal spasm, pericarditis, aortic dissection, gas-troesophageal reflux, neuropathic pain, and anxiety.Myocardial infarction is a serious | Surgery_Schwartz. kidney disease should also be considered.Clinical ManifestationsPatients with CAD may have a spectrum of presentations, including angina pectoris, myocardial infarction, ischemic heart failure, arrhythmias, and sudden death.Angina pectoris is the pain or discomfort caused by myo-cardial ischemia and is typically substernal and may radiate to the left upper extremity, neck, or epigastrium. The variety of presentations can make myocardial ischemia challenging to diagnose. Characteristics of chest pain that make myocardial ischemia less likely include pleuritic chest pain, pain reproduc-ible by movement or palpation, or brief episodes lasting only seconds. Typical angina is relieved by rest and/or use of sub-lingual nitroglycerin. Differential diagnoses to be considered include, but are not limited to, musculoskeletal pain, pulmonary disorders, esophageal spasm, pericarditis, aortic dissection, gas-troesophageal reflux, neuropathic pain, and anxiety.Myocardial infarction is a serious |
Surgery_Schwartz_5391 | Surgery_Schwartz | limited to, musculoskeletal pain, pulmonary disorders, esophageal spasm, pericarditis, aortic dissection, gas-troesophageal reflux, neuropathic pain, and anxiety.Myocardial infarction is a serious consequence of CAD occurring when ischemia results in myocardial necrosis. This may be silent and need not be preceded by angina. Necrosis may result in disruption of the myocardial integrity leading to devastating conditions such as intracardiac shunts from ventric-ular septal defects, acute valvular regurgitation from rupture of necrotic papillary muscles, and cardiac aneurysms, which have the potential for fatal rupture.Ischemic insults from CAD may lead to congestive heart failure. The initial myocardial damage sets off a cascade of both local and systemic responses. Over time, these changes can cause deleterious myocardial loading and abnormal neuro-humoral responses that result in pathologic remodeling of the heart. Heart failure should be suspected in patients who present with | Surgery_Schwartz. limited to, musculoskeletal pain, pulmonary disorders, esophageal spasm, pericarditis, aortic dissection, gas-troesophageal reflux, neuropathic pain, and anxiety.Myocardial infarction is a serious consequence of CAD occurring when ischemia results in myocardial necrosis. This may be silent and need not be preceded by angina. Necrosis may result in disruption of the myocardial integrity leading to devastating conditions such as intracardiac shunts from ventric-ular septal defects, acute valvular regurgitation from rupture of necrotic papillary muscles, and cardiac aneurysms, which have the potential for fatal rupture.Ischemic insults from CAD may lead to congestive heart failure. The initial myocardial damage sets off a cascade of both local and systemic responses. Over time, these changes can cause deleterious myocardial loading and abnormal neuro-humoral responses that result in pathologic remodeling of the heart. Heart failure should be suspected in patients who present with |
Surgery_Schwartz_5392 | Surgery_Schwartz | changes can cause deleterious myocardial loading and abnormal neuro-humoral responses that result in pathologic remodeling of the heart. Heart failure should be suspected in patients who present with dyspnea, orthopnea, fatigue, and edema.Arrhythmias may also be sequelae of CAD. Ischemic etiologies should be investigated in patients who present with new arrhythmias. CAD may result in arrhythmias following an acute MI or as the result of ultrastructural and electrophysi-ologic remodeling secondary to chronic ischemic heart disease. Ischemia of the electrical conduction system may be present in the form of new onset complete or partial atrioventricular conduction blocks.Preoperative EvaluationA focused history and physical examination is essential with par-ticular attention directed to the signs, symptoms, and clinical man-ifestations mentioned previously. The patient’s functional status is of importance not only because it is a component of preoperative risk assessment, but also | Surgery_Schwartz. changes can cause deleterious myocardial loading and abnormal neuro-humoral responses that result in pathologic remodeling of the heart. Heart failure should be suspected in patients who present with dyspnea, orthopnea, fatigue, and edema.Arrhythmias may also be sequelae of CAD. Ischemic etiologies should be investigated in patients who present with new arrhythmias. CAD may result in arrhythmias following an acute MI or as the result of ultrastructural and electrophysi-ologic remodeling secondary to chronic ischemic heart disease. Ischemia of the electrical conduction system may be present in the form of new onset complete or partial atrioventricular conduction blocks.Preoperative EvaluationA focused history and physical examination is essential with par-ticular attention directed to the signs, symptoms, and clinical man-ifestations mentioned previously. The patient’s functional status is of importance not only because it is a component of preoperative risk assessment, but also |
Surgery_Schwartz_5393 | Surgery_Schwartz | the signs, symptoms, and clinical man-ifestations mentioned previously. The patient’s functional status is of importance not only because it is a component of preoperative risk assessment, but also because quality of life improvement and symptomatic relief are both goals of surgical therapy.Coronary angiography is the primary diagnostic tool. The coronary anatomy and degrees of stenoses are delineated allow-ing for planning of surgical revascularization.Noninvasive diagnostic studies, in combination with pro-vocative maneuvers (exercise or pharmacologic agents) offer information regarding the functional significance of ischemic disease. A stress ECG is frequently used as a screening tool with 50% sensitivity and 90% specificity for coronary artery with a threshold of 1 mm of ST-segment depression.38 This test, how-ever, requires patients to achieve a certain elevation in their heart rate and is therefore not suitable for those that cannot achieve this goal. Furthermore, baseline ECG | Surgery_Schwartz. the signs, symptoms, and clinical man-ifestations mentioned previously. The patient’s functional status is of importance not only because it is a component of preoperative risk assessment, but also because quality of life improvement and symptomatic relief are both goals of surgical therapy.Coronary angiography is the primary diagnostic tool. The coronary anatomy and degrees of stenoses are delineated allow-ing for planning of surgical revascularization.Noninvasive diagnostic studies, in combination with pro-vocative maneuvers (exercise or pharmacologic agents) offer information regarding the functional significance of ischemic disease. A stress ECG is frequently used as a screening tool with 50% sensitivity and 90% specificity for coronary artery with a threshold of 1 mm of ST-segment depression.38 This test, how-ever, requires patients to achieve a certain elevation in their heart rate and is therefore not suitable for those that cannot achieve this goal. Furthermore, baseline ECG |
Surgery_Schwartz_5394 | Surgery_Schwartz | This test, how-ever, requires patients to achieve a certain elevation in their heart rate and is therefore not suitable for those that cannot achieve this goal. Furthermore, baseline ECG abnormalities may render it impossible to detect typical ischemic changes with stress.Echocardiography and nuclear imaging may be performed under pharmacologic stress (with dobutamine or dipyridamole) to assess reversible ischemia and myocardial viability. Technetium-99m or thallium-201 perfusion scans and stress echocardiogra-phy are more sensitive than stress ECG.39 These studies also have the ability to assess global ventricular function in terms of left ventricle ejection fraction, which can be used to determine operative risk. Please refer to the diagnostic studies section for more details.CORONARY ARTERY BYPASS GRAFTINGIndicationsA joint committee established by the ACC/AHA have pub-lished guidelines for surgical revascularization (CABG) in Brunicardi_Ch21_p0801-p0852.indd 80901/03/19 5:32 | Surgery_Schwartz. This test, how-ever, requires patients to achieve a certain elevation in their heart rate and is therefore not suitable for those that cannot achieve this goal. Furthermore, baseline ECG abnormalities may render it impossible to detect typical ischemic changes with stress.Echocardiography and nuclear imaging may be performed under pharmacologic stress (with dobutamine or dipyridamole) to assess reversible ischemia and myocardial viability. Technetium-99m or thallium-201 perfusion scans and stress echocardiogra-phy are more sensitive than stress ECG.39 These studies also have the ability to assess global ventricular function in terms of left ventricle ejection fraction, which can be used to determine operative risk. Please refer to the diagnostic studies section for more details.CORONARY ARTERY BYPASS GRAFTINGIndicationsA joint committee established by the ACC/AHA have pub-lished guidelines for surgical revascularization (CABG) in Brunicardi_Ch21_p0801-p0852.indd 80901/03/19 5:32 |
Surgery_Schwartz_5395 | Surgery_Schwartz | ARTERY BYPASS GRAFTINGIndicationsA joint committee established by the ACC/AHA have pub-lished guidelines for surgical revascularization (CABG) in Brunicardi_Ch21_p0801-p0852.indd 80901/03/19 5:32 PM 810SPECIFIC CONSIDERATIONSPART IITable 21-3Algorithm set forth by ACC/AHA guidelines for preoperative cardiovascular evaluation before noncardiac surgery for patients who are scheduled for nonemergent, non-low risk surgery, no active cardiac disease, and less than 3 METsNUMBER OF RISK FACTORSaRECOMMENDATION0Proceed with planned surgery.1–2Control HR and proceed with planned surgery or pursue further testing if it will change management.3–5Pursue further testing if it will advance management.aRisk factors are history of ischemic heart disease, history of prior or compensated heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.Table 21-4Data from ACC/AHA guidelines for CABG in CAD to improve survivalANATOMYCLASS OF RECOMMENDATIONLEVEL OF | Surgery_Schwartz. ARTERY BYPASS GRAFTINGIndicationsA joint committee established by the ACC/AHA have pub-lished guidelines for surgical revascularization (CABG) in Brunicardi_Ch21_p0801-p0852.indd 80901/03/19 5:32 PM 810SPECIFIC CONSIDERATIONSPART IITable 21-3Algorithm set forth by ACC/AHA guidelines for preoperative cardiovascular evaluation before noncardiac surgery for patients who are scheduled for nonemergent, non-low risk surgery, no active cardiac disease, and less than 3 METsNUMBER OF RISK FACTORSaRECOMMENDATION0Proceed with planned surgery.1–2Control HR and proceed with planned surgery or pursue further testing if it will change management.3–5Pursue further testing if it will advance management.aRisk factors are history of ischemic heart disease, history of prior or compensated heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.Table 21-4Data from ACC/AHA guidelines for CABG in CAD to improve survivalANATOMYCLASS OF RECOMMENDATIONLEVEL OF |
Surgery_Schwartz_5396 | Surgery_Schwartz | history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.Table 21-4Data from ACC/AHA guidelines for CABG in CAD to improve survivalANATOMYCLASS OF RECOMMENDATIONLEVEL OF EVIDENCE• LMIB• 3-vessel +/− proximal LADIB• 2-vessel + proximal LADIB• 2-vessel – proximal LADIIa – with extensive ischemiaIIb – without extensive ischemiaBC• Multivessel disease with DMIIa (CABG preferred over PCI)B• Proximal LAD onlyIIa – with LITA for long-term benefitB• 1-vessel – proximal LADIII – HarmB• LV dysfunctionIIa – LVEF 35%–50%IIb – LVEF <35% without LM diseaseBB• Survivor of ischemia-mediated VTIBDM = Diabetes mellitus; LITA = Left internal thoracic/mammary artery; LM = Left main coronary artery; LV = left ventricle; VT = ventricular tachycardia. Class of recommendation: I – Benefit far outweighs risks and procedure should be performed; IIa – Benefit outweighs risks and procedure is considered to be reasonable; IIb – Potential benefits may exceed risks and procedure may be | Surgery_Schwartz. history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.Table 21-4Data from ACC/AHA guidelines for CABG in CAD to improve survivalANATOMYCLASS OF RECOMMENDATIONLEVEL OF EVIDENCE• LMIB• 3-vessel +/− proximal LADIB• 2-vessel + proximal LADIB• 2-vessel – proximal LADIIa – with extensive ischemiaIIb – without extensive ischemiaBC• Multivessel disease with DMIIa (CABG preferred over PCI)B• Proximal LAD onlyIIa – with LITA for long-term benefitB• 1-vessel – proximal LADIII – HarmB• LV dysfunctionIIa – LVEF 35%–50%IIb – LVEF <35% without LM diseaseBB• Survivor of ischemia-mediated VTIBDM = Diabetes mellitus; LITA = Left internal thoracic/mammary artery; LM = Left main coronary artery; LV = left ventricle; VT = ventricular tachycardia. Class of recommendation: I – Benefit far outweighs risks and procedure should be performed; IIa – Benefit outweighs risks and procedure is considered to be reasonable; IIb – Potential benefits may exceed risks and procedure may be |
Surgery_Schwartz_5397 | Surgery_Schwartz | far outweighs risks and procedure should be performed; IIa – Benefit outweighs risks and procedure is considered to be reasonable; IIb – Potential benefits may exceed risks and procedure may be considered; III – Procedure not helpful and may cause harm. Level of evidence: A – Strong; multiple supporting randomized controlled trials or meta-analyses, B – Limited; data based on a single randomized trial or nonrandomized trials, C – Very limited; based on expert consensus, case studies or standards of care.CAD. The indications, categorized by presentation and angio-graphic disease burden as well as by treatment intention (sur-vival improvement and symptom relief), are summarized later (Tables 21-3, 21-4, and 21-5).40,41Percutaneous Coronary Intervention vs. Coronary Artery Bypass GraftingThere have been multiple prospective, randomized, controlled trials as well as large retrospective studies looking at the com-parative effectiveness of percutaneous coronary interventions (PCI) and CABG. | Surgery_Schwartz. far outweighs risks and procedure should be performed; IIa – Benefit outweighs risks and procedure is considered to be reasonable; IIb – Potential benefits may exceed risks and procedure may be considered; III – Procedure not helpful and may cause harm. Level of evidence: A – Strong; multiple supporting randomized controlled trials or meta-analyses, B – Limited; data based on a single randomized trial or nonrandomized trials, C – Very limited; based on expert consensus, case studies or standards of care.CAD. The indications, categorized by presentation and angio-graphic disease burden as well as by treatment intention (sur-vival improvement and symptom relief), are summarized later (Tables 21-3, 21-4, and 21-5).40,41Percutaneous Coronary Intervention vs. Coronary Artery Bypass GraftingThere have been multiple prospective, randomized, controlled trials as well as large retrospective studies looking at the com-parative effectiveness of percutaneous coronary interventions (PCI) and CABG. |
Surgery_Schwartz_5398 | Surgery_Schwartz | have been multiple prospective, randomized, controlled trials as well as large retrospective studies looking at the com-parative effectiveness of percutaneous coronary interventions (PCI) and CABG. Some of the representative studies are sum-marized here.The New York State Study (2005). A retrospective review of 59,314 patients in a New York state registry with multivessel (two or more) coronary disease was performed. Of these, 37,212 patients received a CABG, and the remainder underwent a PCI. After adjusting by means of proportional-hazards methods, CABG was associated with higher adjusted rates of long-term survival than PCI.42Stent or Surgery Trial (2008). An international multicenter, randomized, controlled trial of 988 patients (n = 488 PCI, n = 500 CABG) with multivessel CAD was performed to compare revascularization strategies. The median follow-up was extended to 6 years, and a survival advantage persisted in the CABG group over the PCI group.43Synergy Between Percutaneous | Surgery_Schwartz. have been multiple prospective, randomized, controlled trials as well as large retrospective studies looking at the com-parative effectiveness of percutaneous coronary interventions (PCI) and CABG. Some of the representative studies are sum-marized here.The New York State Study (2005). A retrospective review of 59,314 patients in a New York state registry with multivessel (two or more) coronary disease was performed. Of these, 37,212 patients received a CABG, and the remainder underwent a PCI. After adjusting by means of proportional-hazards methods, CABG was associated with higher adjusted rates of long-term survival than PCI.42Stent or Surgery Trial (2008). An international multicenter, randomized, controlled trial of 988 patients (n = 488 PCI, n = 500 CABG) with multivessel CAD was performed to compare revascularization strategies. The median follow-up was extended to 6 years, and a survival advantage persisted in the CABG group over the PCI group.43Synergy Between Percutaneous |
Surgery_Schwartz_5399 | Surgery_Schwartz | performed to compare revascularization strategies. The median follow-up was extended to 6 years, and a survival advantage persisted in the CABG group over the PCI group.43Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX Trial, 2009, updated 2013). Revascularization strategies, CABG vs. PCI, were compared in a 1:1 randomized prospective trial of 1800 patients with high-risk coronary artery disease (left-main or triple-vessel disease). Rates of requirement for repeat revascu-larization and major adverse cardiac or cerebrovascular events (MACCE) at 1 year were lower in the CABG patients (5.9% and 12.4%, respectively) compared to PCI patients (13.5% and 17.8%, respectively). No difference in mortality was seen between the groups at 1 year.44 At 5 years, the estimated rate of MACCE was 26.9% in the CABG group vs. 37.3% in the PCI group. No difference in all-cause mortality was seen. The dif-ference in MACCE between PCI and CABG was confined to | Surgery_Schwartz. performed to compare revascularization strategies. The median follow-up was extended to 6 years, and a survival advantage persisted in the CABG group over the PCI group.43Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX Trial, 2009, updated 2013). Revascularization strategies, CABG vs. PCI, were compared in a 1:1 randomized prospective trial of 1800 patients with high-risk coronary artery disease (left-main or triple-vessel disease). Rates of requirement for repeat revascu-larization and major adverse cardiac or cerebrovascular events (MACCE) at 1 year were lower in the CABG patients (5.9% and 12.4%, respectively) compared to PCI patients (13.5% and 17.8%, respectively). No difference in mortality was seen between the groups at 1 year.44 At 5 years, the estimated rate of MACCE was 26.9% in the CABG group vs. 37.3% in the PCI group. No difference in all-cause mortality was seen. The dif-ference in MACCE between PCI and CABG was confined to |
Surgery_Schwartz_5400 | Surgery_Schwartz | years, the estimated rate of MACCE was 26.9% in the CABG group vs. 37.3% in the PCI group. No difference in all-cause mortality was seen. The dif-ference in MACCE between PCI and CABG was confined to patients with intermediate or high SYNTAX scores.45The ACCF and STS Database Collaboration on the Com-parative Effectiveness of Revascularization Strategies (ASCERT Study, 2012). This study, performed by collabo-ration of the American College of Cardiology Foundation and the Society of Thoracic Surgeons, reviewed their respective national databases of patients over the age of 65 who had multi-vessel coronary disease (excluding those with left main disease). CABG was performed on 86,244 patients, and 103,549 under-went PCI. There was no difference in adjusted mortality at 1 year, but there was a significantly lower mortality with CABG than PCI at 4 years.46 Although CABG had higher cost, this was Brunicardi_Ch21_p0801-p0852.indd 81001/03/19 5:32 PM 811ACQUIRED HEART DISEASECHAPTER | Surgery_Schwartz. years, the estimated rate of MACCE was 26.9% in the CABG group vs. 37.3% in the PCI group. No difference in all-cause mortality was seen. The dif-ference in MACCE between PCI and CABG was confined to patients with intermediate or high SYNTAX scores.45The ACCF and STS Database Collaboration on the Com-parative Effectiveness of Revascularization Strategies (ASCERT Study, 2012). This study, performed by collabo-ration of the American College of Cardiology Foundation and the Society of Thoracic Surgeons, reviewed their respective national databases of patients over the age of 65 who had multi-vessel coronary disease (excluding those with left main disease). CABG was performed on 86,244 patients, and 103,549 under-went PCI. There was no difference in adjusted mortality at 1 year, but there was a significantly lower mortality with CABG than PCI at 4 years.46 Although CABG had higher cost, this was Brunicardi_Ch21_p0801-p0852.indd 81001/03/19 5:32 PM 811ACQUIRED HEART DISEASECHAPTER |
Surgery_Schwartz_5401 | Surgery_Schwartz | was a significantly lower mortality with CABG than PCI at 4 years.46 Although CABG had higher cost, this was Brunicardi_Ch21_p0801-p0852.indd 81001/03/19 5:32 PM 811ACQUIRED HEART DISEASECHAPTER 21Table 21-5Data from ACC/AHA guidelines for CABG in CAD to improve symptomsANATOMY ASSOCIATED SYMPTOMSCLASS OF RECOMMENDATIONLEVEL OF EVIDENCE• Unacceptable angina with presence of ≥1 stenoses amenable to revascularization despite medical treatmentIA• Complex 3-vessel CAD +/− proximal LAD involvementIIa (CABG preferred over PCI)B• Unacceptable angina with presence of ≥1 stenoses amenable to revascularization but medical treatment is not possibleIIaC• Previous CABG with ≥1 stenoses associated with ischemia and angina despite medical treatmentIIbCmodest with an incremental cost-effectiveness ratio of $30,454 per quality-adjusted life year gained.47Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL Trial, 2016). This study randomized 1905 patients with | Surgery_Schwartz. was a significantly lower mortality with CABG than PCI at 4 years.46 Although CABG had higher cost, this was Brunicardi_Ch21_p0801-p0852.indd 81001/03/19 5:32 PM 811ACQUIRED HEART DISEASECHAPTER 21Table 21-5Data from ACC/AHA guidelines for CABG in CAD to improve symptomsANATOMY ASSOCIATED SYMPTOMSCLASS OF RECOMMENDATIONLEVEL OF EVIDENCE• Unacceptable angina with presence of ≥1 stenoses amenable to revascularization despite medical treatmentIA• Complex 3-vessel CAD +/− proximal LAD involvementIIa (CABG preferred over PCI)B• Unacceptable angina with presence of ≥1 stenoses amenable to revascularization but medical treatment is not possibleIIaC• Previous CABG with ≥1 stenoses associated with ischemia and angina despite medical treatmentIIbCmodest with an incremental cost-effectiveness ratio of $30,454 per quality-adjusted life year gained.47Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL Trial, 2016). This study randomized 1905 patients with |
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