Functional Anatomy of the Aortic Valve The aortic valve is the last of four cardiac valves through which the blood is pumped before it goes to the rest of the body. It separates the left ventricular outflow tract from the aorta. Its main function is to prevent backward blood flow from the aorta to the left ventricle, while allowing the blood to flow forward during systole…
The Ideal Valve Many acceptable substitutes exist today for the replacement of diseased human heart valves. The ideal valvular prosthesis as described by Harken remains the gold standard of cardiac surgery. According to Harken this valve would be durable, with a longevity approaching that of a native valve, thrombogenicity would not be a factor, and therefore no need for supplemental anticoagulation would exist. In addition, this…
The heart is a vital organ, with its arch vessels encased in the chest cavity and protected by the manubrium, sternum, and rib cage. Injury to this organ can come from blunt trauma, which includes blunt cardiac injury, more commonly referred to as cardiac contusion, coronary artery injury, atrial/ventricular/valvular rupture, and aortic or arch vessel rupture. Injury can also result from penetrating trauma, with the right…
Peripheral arterial occlusive disease (PAD) is a major cause of disability, loss of work, and lifestyle changes. The natural history of PAD is often characterized by slow progression in symptoms over time. However, 70% of patients will remain stable or improve over time, approximately 30% will require an intervention, and 10% will require amputation. Limb loss is the tragic final outcome of PAD and is associated…
* Disclosure: Dr. Coselli serves as a consultant for Vascutek Ltd., a subsidiary of Terumo Corporation. Frequently, and in a variety of clinical settings, cardiovascular surgeons encounter occlusive disease involving the branches arising from the aortic arch. As a result of the increasing average life expectancy of human beings, there is a growing subset of older patients who are found to have brachiocephalic occlusive disease incidentally…
The development of thoracic endovascular aortic repair (TEVAR) has dramatically revolutionized the field of cardiovascular surgery. Since Parodi's first description of an intraluminal stent graft device for the treatment of abdominal aortic aneurysms, endovascular device technology has rapidly evolved to treat the multiple pathologies seen in the thoracic aorta. In 1994, Dake first reported the initial Stanford experience with 13 patients undergoing endovascular therapy of descending…
Occurring more frequently than ruptured abdominal aortic aneurysm, aortic dissection is the most common catastrophe involving the aorta. Because major aortic branch occlusion can complicate the clinical presentation of patients with acute dissection and thus mimic many other acute medical and surgical problems, a high index of clinical suspicion is necessary to diagnose this life-threatening condition early. The lethal nature of acute aortic dissection mandates prompt…
Acute aortic dissection is one of the most common catastrophes involving the aorta. Dissection of the aorta is characterized by the separation of the aortic media by pulsatile blood, with variable extents of proximal and distal extension along the aorta and its branches. The process of dissection creates a false lumen in the aortic wall that parallels the aortic true lumen. In the majority of cases,…
Introduction Aortic aneurysm is defined as a localized dilation of the aorta that is at least 50% greater than that of nondiseased adjacent aorta. In the distal aorta, namely the descending thoracic and thoracoabdominal aorta, most aneurysms form as a result of nonspecific medial degeneration, expansion related to chronic aortic dissection, or the disease processes of connective tissue disorders. Whereas aortic aneurysms may be either fusiform…
The history of cardioaortic surgery has been replete with new techniques for ascending and aortic arch repairs since 1956, when Denton Cooley and Michael DeBakey replaced the ascending aorta with a homograft using cardiac bypass. In 1957, DeBakey and colleagues first described aortic arch replacement using antegrade brain perfusion. Before this, one of the few successful ascending aortic repairs was reported in 1932 by Blalock, who…
Functional Anatomy of the Aortic Root The aortic root is the anatomic segment between the left ventricle and the ascending aorta. It contains the aortic valve and other anatomic elements, which function as a unit. The aortic root has several anatomic components: the subcommissural triangles, the aortic annulus, the aortic cusps, the aortic sinuses or sinuses of Valsalva, and the sinotubular junction. The subcommissural triangles are…
At the turn of the 20th century, Dr. Ernest A. Codman (1869-1940) was rejected by the Boston medical community for his maverick ideas supporting the evaluation and publication of surgical outcomes. Codman eventually founded his own hospital dedicated to the study of “end results” and published his outcomes. His work was seminal in the establishment of the American College of Surgeons and the Joint Commission. A…
Despite meticulous adherence to presently known principles of myocardial protection, perioperative myocardial damage related to ischemia-reperfusion injury continues to occur after cardiac operations that have been performed in a technically adequate manner. Ischemia-reperfusion injury associated with surgically induced myocardial ischemia secondary to aortic cross-clamping results from the attenuation or cessation of coronary blood flow such that oxygen delivery to the myocardium is insufficient to meet basal…
Most cardiac surgery procedures are performed through a median sternotomy, an approach pioneered by Milton in 1897. Although fairly uncommon, infective complications for this type of incision remain a difficult challenge for cardiac surgeons. Definition Sternal wound complications have been classified by El Oakley and Wright as follows: 1 Mediastinal dehiscence: median sternotomy wound breakdown in the absence of clinical or microbiologic evidence of infection. 2…
Introduction and History Cardiopulmonary bypass (CPB) is one of the most important biomedical inventions in the history of health care, rivaling the development of roentgenography and hemodialysis in its clinical impact. The scope of its application is far reaching. Its birth paralleled the evolution of an entire surgical subspecialty, and without its use, surgeons would be intimidated by the prospect of intracardiac repair. Despite the belief…
The brain is the effector organ for all behavior, innate and learned. It is the monarch of blood flow and will shut down all other vascular systems to preserve its own supply. Conversely, dysfunction in other organs can adversely affect brain function. It monitors other organ systems and is acutely sensitive and responsive to both the external and internal environment. Thus, even small injuries to the…
In contrast to set-piece wars of the past, modern warfare is characterized by a “nonlinear” battlefield with intermittent engagements of an elusive enemy. Soldiers wear advanced protective gear including helmets, ballistic eyewear, ceramic torso plates, and Kevlar neck, arm, and groin pieces. Even transport vehicles are surrounded in ballistic armor. In addition to typical weapons such as high-velocity automatic rifles, mortars, and grenades, high-energy improvised explosive…
This chapter will familiarize providers with the expected management of patients following adult cardiac surgery using a systematic approach. The common and important side effects or complications of cardiac surgery are described, and their managements are reviewed. The provided references support evidence-based approaches to common postoperative conditions and represent important sources for more detailed analysis of individual topics. The chapter is not meant to be comprehensive…
Anesthesia was successfully demonstrated for the first time in 1846. Prior to that time, it was deemed impossible to perform major surgical procedures because of the associated pain and discomfort. Anesthesia has been one the greatest catalysts in the evolution of surgery since the 1840s. The first successful cardiac surgical procedure occurred in 1902, when Hill closed a stab wound to the heart of a 13-year-old…
Heart failure has become an increasingly important cause of morbidity and mortality in the United States and in other industrialized nations. Despite improvement in heart failure treatment, its prevalence continues to rise, in large part as a result of the aging of the population and the improved survival of heart failure patients. In 2010, the most recent year for which statistics are available, the estimated prevalence…