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Left Ventricular Assist Devices and Total Artificial Heart

Mechanical circulatory support (MCS) has become the standard of care for patients with refractory, end-stage heart failure. A landmark trial in MCS demonstrated the superiority of a left ventricular assist device (LVAD) over optimal medical therapy with respect to improving survival and quality of life in this subgroup of patients. Over the past decade, there has been a significant evolution in MCS device-related technologies. Devices have…

Surgical Management of Hypertrophic Cardiomyopathy

Definition Hypertrophic cardiomyopathy (HCM), the most common genetic cardiac disease, occurs in approximately 1 in 500 young adults. It is defined as left ventricular (LV) hypertrophy in the absence of an underlying cause, such as systemic hypertension or valvular aortic stenosis. In the obstructive form of HCM, septal hypertrophy and abnormal systolic anterior motion of the mitral valve combine to produce left ventricular outflow tract (LVOT)…

Pericardium and Constrictive Pericarditis

The Pericardium History The earliest descriptions of the pericardium date back to Hippocrates (460 to 377 bc ). Galen ( ad 129 to 210) described the protective function of the pericardium and also reported a pericardial effusion in animals. Avenzoar (1091 to 1162) described pericarditis, and Vesalius (1514 to 1564) carefully documented the anatomy of the pericardium. Jean Riolan (1649) suggested treating pericarditis with trephination of…

Nonatherosclerotic Coronary Artery Disease

Greater than 95% of patients with myocardial ischemia will have underlying atherosclerotic coronary artery disease as the etiology, with the remaining 5% possessing a range of congenital and acquired lesions. Although these lesions are rare individually, clinicians will inevitably encounter some form of nonatherosclerotic coronary artery disease in their practice. These disorders can be broadly classified as congenital or acquired. Congenital coronary anomalies occur secondary to…

Postinfarction Ventricular Septal Defect and Ventricular Rupture

Disruption of the ventricular septum after myocardial infarction is an infrequent event after a full-thickness myocardial infarction. The resulting clinical syndrome can range from an asymptomatic murmur to an extensive left-to-right intracardiac shunt with resulting heart failure and shock. The first approaches to surgical management emphasized delayed repair, which allowed time for fibrosis to occur so that tissue quality at the defect margins was more substantial.…

Ischemic Mitral Regurgitation

Significant advances have been made in the treatment of ischemic cardiomyopathy; however the presence of mitral regurgitation in this population continues to be a significant risk factor for mortality. This chapter addresses the current concepts regarding the pathophysiology, decision making, and treatment of ischemic mitral regurgitation. Definition Carpentier's pathophysiologic triad is our preferred approach for defining ischemic mitral regurgitation. Most of the clinical literature on ischemic…

Re-Do Coronary Artery Bypass Surgery

Reoperations present coronary surgeons with their greatest challenges. Patients undergoing reoperation for bypass grafting are different from those who undergo primary surgery. In addition to the risks of a repeated median sternotomy, their coronary artery and noncardiac atherosclerosis is more advanced, noncardiac comorbidities are more common, ventricular function is more likely to be abnormal, and the vascular pathologic processes that jeopardize myocardium are distinct and varied.…

Robotic and Alternative Approaches to Coronary Artery Bypass Grafting

Robotic and Alternative Approaches to Coronary Artery Bypass Grafting The standard approach for coronary artery bypass grafting (CABG) is median sternotomy using cardiopulmonary bypass. However, less invasive approaches, including off-pump CABG and smaller access surgeries with or without robotic assistance, have been developed. This chapter describes less invasive methods of coronary revascularization along with their associated outcomes, with emphasis on robotic CABG. Hybrid coronary revascularization techniques…

Off-Pump Coronary Artery Bypass Grafting and Transmyocardial Laser Revascularization

In 1967, Sabiston and colleagues reported the first clinically successful coronary artery bypass graft (CABG) operation. Other early pioneers include Favaloro, who is credited with popularizing the use of autogenous saphenous vein, and Kolesov, who performed the first mammary artery to coronary artery anastomosis. Over the next several years, centers around the world began performing CABG procedures in large numbers. Subsequent refinements in cardiopulmonary bypass (CPB),…

Coronary Artery Bypass Grafting

Coronary artery bypass grafting (CABG) is among the most important surgical procedures in the history of medicine. Arguably, no other operation has prolonged more lives, provided more symptom relief, and been more thoroughly investigated. CABG has been the most common procedure of adult cardiac surgery, but its future is increasingly threatened by medical and percutaneous alternatives. However, CABG is evolving with less invasive options, better postoperative…

Surgical Treatment of Cardiac Arrhythmias

Current nonpharmacologic treatments for cardiac arrhythmias include catheter ablation, implantation of pacemakers and cardioverter-defibrillator devices, and surgery. These modalities can be used to treat essentially all supraventricular and ventricular tachyarrhythmias. Although the indications for surgical intervention have narrowed, surgery remains an important treatment option, especially for the most common of all arrhythmias, atrial fibrillation. Atrial Fibrillation Background Atrial fibrillation (AF) is present in up to 2%…

Catheter Ablation of Arrhythmias

Over the past 40 years, cardiac electrophysiology has progressed from an esoteric field dedicated to understanding arrhythmia mechanisms to an indispensable modality in the diagnosis and treatment of cardiac arrhythmias. Electrophysiology therapeutics first began with cardiac surgery for the treatment of arrhythmias. After it became clear that invasive surgical strategies could cure arrhythmias, methods for delivery of energy through catheter-based techniques were developed. The advent of…

Cardiac Devices for the Treatment of Bradyarrhythmias and Tachyarrhythmias

Historical Perspective and Overview Paul Zoll developed the first transcutaneous electronic pacemaker in 1952 for the treatment of life-threatening bradycardia. The first internal pacemaker was implanted in 1958 for the treatment of complete heart block and in the management of Stokes-Adams seizures. Early pacemaker models were simple, fixed-rate devices. Thoracic surgeons performed most early implants by placing epimyocardial leads directly on the exposed heart; these leads…

Robotic and Minimally Invasive Mitral Valve Surgery

Cardiac surgery has traditionally been performed through a complete median sternotomy, which provides generous operative exposure to all structures in and around the heart. With this approach, complex cardiovascular procedures can be performed safely and effectively. Reductions in incision size and tissue manipulation became possible with the advent of closed-chest cardiopulmonary techniques and advances in instrumentation. Improvements in intracardiac visualization and robotic telemanipulation have pushed the…

Anticoagulation, Thrombosis, and Thromboembolism of Prosthetic Cardiac Valves

Artificial Surfaces, Coagulation Cascades, Thrombosis, and Lysis Intravascular placement of a foreign body with its nonendothelial surface activates the clotting mechanism, leading to thrombus formation. The exposure of blood to the synthetic surface leads rapidly to deposition of a fine layer of plasma components, mostly protein, followed by platelet deposition. The intrinsic coagulation cascade is initiated along with the extrinsic coagulation cascade: the inflammatory response, including…

Native and Prosthetic Valve Endocarditis

Endocarditis of a patient's native heart valve is defined as native valve endocarditis (NVE), and endocarditis of a prosthetic device is termed prosthetic valve endocarditis (PVE). The incidence of NVE in developed countries is approximately 1.7 to 7.0 cases out of 100,000 persons per year and is highest in older adults. NVE typically affects the left heart, with right heart involvement observed in only 5% to…

Surgical Treatment of Tricuspid Valve Diseases

The tricuspid valve is often ignored by cardiologists and surgeons because of its unique characteristics. It is frequently called “The Forgotten Valve,” and there still is scant information regarding the effects of tricuspid valve diseases on the prognosis of cardiac patients. With the exception of infective endocarditis, primary isolated lesions of the tricuspid valve are rare. There are just a few reports on isolated congenital, rheumatic,…

Surgical Treatment of the Mitral Valve

Anatomy The mitral valve apparatus is composed of the mitral annulus, leaflets, chordae tendineae, papillary muscles, and the left ventricular lateral wall ( Fig. 80-1 ). Chordae tendineae and papillary muscles comprise the subvalvular apparatus. Annulus The right fibrous trigone is a dense fibrous area of continuity between the annuli of the mitral, tricuspid, and noncoronary cusp of the aortic valve, as well as the membranous…

Transcatheter Aortic Valve Replacement

Introduction Aortic stenosis is the most frequent acquired valve disease in older adult patients; consequently, the number of patients requiring treatment increases as the population ages. Current U.S. Census predictions indicate that by 2050 the number of citizens 85 years and older will reach 17.9 million and the number of citizens 65 years and older will reach 83.7 million. Historically, aortic stenosis was treated with surgical…

Aortic Valve Repair

Aortic valve replacement remains the gold standard for the treatment of severe aortic valve disease. However, valve repair is emerging as a feasible and attractive alternative to valve replacement in selected patients. Valve repair can reduce or eliminate the risks of prosthesis-related complications including thromboembolism, endocarditis, anticoagulant-related hemorrhage, and reoperation owing to structural valve deterioration among others. Analogous to the mitral valve, a reconstructive approach to…