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Medical Management of Acute Coronary Syndromes

Acute Coronary Syndrome Definition Acute coronary syndrome (ACS) refers to a constellation of clinical symptoms (usually including some type of chest discomfort) that is compatible with acute myocardial ischemia. Patients with suspected ACS may eventually prove to have a diagnosis other than ischemia. However, true ACS can be classified into the following clinical subsets: 1 ST-segment elevation myocardial infarction (STEMI). 2 Non–ST-segment elevation ACS (NSTEACS). This…

Interventional Cardiology

Interventional cardiology is a subspecialty of medicine that treats a variety of cardiovascular disorders using catheter-based therapeutics. Despite its humble beginnings in 1977, interventional cardiology now includes an array of procedures and techniques for the treatment of ischemic, valvular, and congenital heart disorders. The growth and maturation of the discipline have closely paralleled the rapid influx of new technologies and pharmacotherapeutics. This chapter will review the…

Diagnostic Echocardiography (Ultrasound Imaging in Cardiovascular Diagnosis)

Echocardiography has broad utility in the diagnosis and management of cardiovascular disease. Echocardiography allows for real-time, precise anatomic definition and physiologic interrogation of cardiac and vascular structures at relatively low cost with minimal patient risk and discomfort. Common clinical applications for echocardiography include assessment of myocardial and valvular function, identification of structural abnormalities, and optimizing timing for surgical intervention. Echocardiography has expanded beyond the diagnostic laboratory…

Nuclear Cardiology and Positron Emission Tomography in the Assessment of Patients with Cardiovascular Disease

Introduction to Nuclear Cardiology Nuclear cardiology involves the imaging of cardiac radiopharmaceutical distribution to characterize physiologic and pathophysiologic processes in the heart. The ability to image myocardial perfusion, function, and metabolism noninvasively with nuclear techniques has led to the development of a field that has been validated extensively and provides powerful diagnostic and prognostic information in the management of patients with known or suspected coronary artery…

Applications of Cardiovascular Magnetic Resonance and Computed Tomography in Cardiovascular Diagnosis

Cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) are increasingly used in the diagnosis and management of cardiovascular disease. Both of these advanced imaging modalities have overcome similar challenges posed by cardiac and respiratory motion and have met the demand for high temporal and spatial resolution to enable noninvasive imaging to aid in the diagnosis and management of a variety of cardiovascular disorders. In addition,…

Coronary Angiography: Valve and Hemodynamic Assessment

Cardiac catheterization and coronary angiography are essential tools in the diagnosis and evaluation of coronary and valvular heart disease, with several million procedures performed annually in the United States. Significant technological advances have occurred since the insertion of the first intravascular catheter by Werner Forsman in the 1920s, the first selective coronary catheterization by F. Mason Sones in 1956, and the first coronary angioplasty by Andreas…

Blood Coagulation, Transfusion, and Conservation

Following cardiac surgery, multiple quantitative and qualitative hemostatic abnormalities have been described. Preexisting and acquired defects contribute to bleeding. The increasing use of anticoagulants, including antiplatelet agents (clopidogrel, prasugrel, ticagrelor) and new oral anticoagulation (NOAC) agents (dabigatran, rivaroxaban and apixaban), contributes to a preoperative hemostatic defect. These events produce a complex hemostatic alteration that is further complicated by heparin and cardiopulmonary bypass, which cause additional acquired…

Ventricular Mechanics

In this chapter, we will examine the mechanics of the heart at the tissue and organ level. The chapter will focus primarily on the left ventricle (LV), but short discussions of left atrial function as it relates to LV filling and ventricular interaction will be included. First, we will review several important myocardial structural elements, an understanding of which is necessary for the understanding of function…

Physiology of the Myocardium

Integrative Biology of the Myocardium The essential function of the muscles that make up the myocardium is to transfer to the arteries the volume of blood added to the ventricular chambers during diastole. This transfer must occur within the narrow limits of end-diastolic pressures and must produce a flow of materials to the organs that matches the needs of the cells. The term needs means “matching…

Vascular Physiology

Myocardial and pulmonary perfusion is regulated by a complex array of influences intrinsic and extrinsic to the vasculature. Surgical decisions are generally based on the anatomy of large arteries, where the presence of obstructive lesions and vasomotor state of these vessels can affect myocardial, pulmonary, or other organ perfusion. Under normal circumstances, the microcirculation actually plays a more significant role in the regulation of blood flow.…

Surgical Anatomy of the Heart

† Deceased. In this chapter, we provide a brief overview of cardiac structure as it is relevant for the cardiac surgeon. We describe the heart as it is located in the body in its anatomic, or attitudinally correct, position. Whenever possible, however, we illustrate the cardiac components as they would be viewed by the surgeon during an operative procedure, whether the pictures were taken in the…

Innovative Therapy and Technology

Lung cancer remains the number one cause of cancer-related deaths in men and women, and the incidence continues to rise with approximately 175,000 new cases diagnosed annually in the United States. In this chapter, we review several innovative therapies for patients who are at high risk for primary and metastatic lung tumors. Application of these new therapies continues to evolve, and in most cases, surgical resection…

The Molecular Biology of Thoracic Malignancies

As Dr. Blake Cady eloquently stated, tumor biology is the principle determinant of outcome in surgical oncology. “Biology is King, Selection is Queen, and the technical details of surgical procedures are the Princes and Princesses of the realm who frequently try to overthrow the powerful forces of the King and Queen, usually to no long-term avail, although with some temporary apparent victories.” Reflections such as this…

Surgical Treatment of Hyperhidrosis

Hyperhidrosis is a pathologic condition characterized by excessive sweating beyond what is required for normal physiologic thermoregulation. This overproduction causes a significant psychosocial affliction that can negatively affect an individual's quality of life. The incidence of hyperhidrosis depends on the culture, on the climate, and on subjective definitions. Hyperhidrosis affects 1% to 3% of the U.S. population, but this percentage is likely underestimated because of infrequent…

The Posterior Mediastinum

The posterior mediastinum is an anatomically diverse region that includes visceral organs, major vascular structures, large neural structures, and important lymphatic vessels. Lesions that originate in the mediastinum are relatively rare compared with the diverse pathology that can involve the mediastinum secondarily, although metastatic disease appearing in the posterior mediastinum, excluding the spine, is unusual. The most common lesions arising within the posterior mediastinum are primarily…

The Middle Mediastinum

Anatomy Using the traditional “three-compartment” classification, the middle mediastinum is bounded anteriorly by the pericardium and posteriorly by the pericardium and membranous wall of the trachea ( Fig. 42-1 ). The lateral borders are composed of the mediastinal pleura, while the superior margin is the thoracic inlet and the inferior margin is the diaphragm. Contained within this space are portions of the airway, the pericardial contents,…

Anterior Mediastinal Masses

Although the anatomy of the mediastinum is presented in detail elsewhere in this book, it is reviewed here from a thoracic surgical perspective to highlight the radiographic and surgical anatomic subdivisions of the mediastinum that have been proposed. The simplest and most commonly used description is the three-compartment model proposed by Shields. He divided the mediastinum into the anterior compartment, the middle (or visceral) compartment, and…

Mediastinal Anatomy and Mediastinoscopy

Mediastinal Anatomy The anatomic boundaries of the mediastinum include the thoracic inlet superiorly, the diaphragm inferiorly, the sternum anteriorly, the spine posteriorly, and the pleural spaces bilaterally. It is convenient to divide the mediastinum into anatomic compartments that provide a method for classification of disease processes. A classic description divides the mediastinum into four compartments: superior, anterior, middle, and posterior ( Fig. 40-1 ). The superior…

Multimodality Therapy for Esophageal Cancer

Overview: Principles of Multimodality Therapy Achieving real improvement in the treatment outcomes for esophageal cancer has been a slow process. Arguably, the major hurdles impeding our ability to diagnose and treat the disease were, for the most part, overcome in the last century. Establishing reliable and safe anesthetic techniques for thoracic surgery and minimizing mortality from an esophageal resection while maximizing local/regional control (to the extent…

Esophageal Resection and Replacement

The prevalence of esophageal adenocarcinoma has risen dramatically over the past three decades. Esophageal cancer is the eighth most common cancer worldwide, and more than 480,000 new cases were diagnosed in 2008. The documented increase is approximately six- to sevenfold, with adenocarcinoma now contributing to approximately 80% of the esophageal cancer surgical workload in many surgical units. This increase is unprecedented and has occurred at a…