Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Approaches and Techniques for Extracorporeal Membrane Oxygenation

◆ Extracorporeal membrane oxygenation (ECMO) pertains to prolonged extracorporeal cardiopulmonary bypass using intrathoracic or extrathoracic vascular cannulation. The bypass circuit includes a distensible venous blood reservoir receiving deoxygenated blood from the patient passing through a nonocclusive centrifugal pump toward the membrane oxygenator and countercurrent heat exchanger to be delivered finally to the patient via an arterial or venous cannula ( Fig. 31.1 ). To prevent thrombosis…

Surgery for Left Ventricular Aneurysm and Remodeling

◆ Amelioration of left ventricular (LV) remodeling is an appealing target for medical and surgical therapies for heart failure. Remodeling is a complex process that leads to maladaptive ventricular dilation, hypertrophy, and altered ventricular wall stress and may occur after large myocardial infarction, chronic ischemia, or chronic valvular heart disease. ◆ The most distinct sequela of remodeling is aneurysm formation at the site of infarction. Transmural…

Surgery for Hypertrophic Cardiomyopathy

Step 1 Surgical Anatomy ◆ Knowledge of the anatomy involved with hypertrophic cardiomyopathy (HCM) is paramount in understanding the pathophysiology that ultimately contributes to dynamic subaortic obstruction. ◆ HCM is defined as left ventricular (LV) hypertrophy in the absence of another underlying cause, such as aortic valve stenosis, systemic hypertension, or metabolic disorders, such as Fabry disease or amyloidosis. ◆ Septal hypertrophy and systolic anterior motion…

Surgery for Atrial Fibrillation

Atrial Fibrillation ◆ Atrial fibrillation (AF) is a supraventricular tachyarrhythmia that is projected to affect 12 million patients in the United States by 2050; prevalence is increased in older people and in patients with hypertension, heart failure, coronary artery disease (CAD), valvular heart disease, obesity, diabetes mellitus, and chronic kidney disease (CKD). AF is present in up to 50% of patients undergoing mitral valve surgery and…

Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic and Aortic Arch Aneurysms

Summary ◆ Thoracic endovascular aortic repair (TEVAR) has become an effective treatment for various descending thoracic aortic pathologic processes, including aortic aneurysm and dissection. Although long-term outcome data for this therapy are not available, the short-term and intermediate results have been promising. Long-term data is accumulating and appears to be comparable to open surgery. ◆ Multiple devices have been investigated and approved in multicenter trials. Multiple…

Thoracoabdominal Aneurysms

See Video 26.1 on ExpertConsult.com . Step 1 Surgical Anatomy ◆ Thoracoabdominal aortic aneurysms (TAAAs) are characterized by dilation of the aorta (to at least 1.5 times its normal diameter) at the diaphragmatic hiatus—the boundary that separates the descending thoracic and abdominal aortic segments—with varying degrees of extension into the chest and abdomen. ◆ The normal diameter of the aorta varies by anatomic location and by…

Aortic Arch Aneurysms

Step 1 Surgical Anatomy ◆ Academic anatomists refer to the aortic arch as that part of the aorta that begins and ends with a line drawn in cross section across the aorta at a level corresponding to the lesser curve of the aortic arch. This therefore implies that the arch of the aorta starts at approximately the level of the superior reflection of the pericardial sac.…

Type A Aortic Dissections

Step 1 Surgical Anatomy ◆ Type A dissection is defined by the presence of a septum creating two lumens within the ascending aorta. The DeBakey classification further divides the Stanford type A classification according to whether the septum is located solely in the ascending aorta (DeBakey type II) or extends distally within the arch and thoracoabdominal aorta (DeBakey type I; Fig. 24.1 ). ◆ The septum…

Tricuspid Valve Operations

Step 1 Surgical Anatomy ◆ The tricuspid valve is located between the right atrium (RA) and right ventricle and has a valve area of 4 to 6 cm. The tricuspid valve is composed of three leaflets—the anterior, posterior, and septal. The leaflets are supported by chordae tendineae and papillary muscles. Compared with the mitral valve, the leaflets and chordae tendineae of the tricuspid valve are thinner and…

Percutaneous Mitral Valve Repair Techniques

Step 1 Surgical Anatomy ◆ Percutaneous therapies have changed how the modern cardiothoracic surgeon approaches the treatment of valvular heart disease. Although much of this evolution has come with the advent of transcatheter aortic valve replacement, considerable obstacles inherent to mitral valve disease have been overcome to develop multiple percutaneous technologies. ◆ Surgery is often difficult because mitral valve disease is both caused by and develops…

Robotic Mitral Valve Surgery

◆ The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines strongly recommend (class I) prompt surgical correction of mitral regurgitation (MR) for patients in stages D (severe symptomatic MR) and C2 (severe asymptomatic MR with left ventricular ejection fraction [LVEF] < 60% or left ventricular end-systolic diameter [LVESD] > 40 mm). Recently, several studies have supported the advantages of surgical correction of primary MR, even…

Minimally Invasive Mitral Valve Surgery: Partial Sternotomy Approach

◆ Mitral valve dysfunction is a common pathologic process. The process may involve any component of the valve or subvalvular structures, including the valve leaflets, the annulus, the papillary muscles, the chordae tendineae, and the left ventricular wall. ◆ The anatomic description of the mitral valve is best visualized using a three-dimensional approach to its location in the heart. The anterior portion of the mitral valve…

Mitral Valve Replacement

Step 1 Anatomy ◆ The mitral valve is a complex structure comprised of an anterior and posterior leaflet that is connected to the left ventricle via attachments to papillary muscles through the chordae tendineae. ◆ It is anchored to the mitral annulus, which is in close relation to the circumflex coronary artery laterally, coronary sinus medially, and aortic valve anteriorly. ◆ Shown in Fig. 19.1 is…

Repairing Degenerative Mitral Valve Disease

Introduction ◆ Degenerative mitral valve disease, also called mitral valve prolapse or floppy mitral valve syndrome , is caused by myxomatous degeneration of the mitral valve tissue, whereby elastin and collagen bundles are disrupted, and proteoglycan deposition in the spongiosa results in leaflet thickening and redundancy. This, in turn, can cause impaired leaflet coaptation, chordal elongation or rupture, and annular dilation, resulting in mitral regurgitation. ◆…

Ross Procedure

◆ The Ross procedure replaces the diseased aortic valve with a viable pulmonary autograft and uses an appropriate conduit (e.g., a cryopreserved pulmonary homograft) to reconstruct the right ventricular outflow tract (RVOT). ◆ As initially described, the autograft was placed as a scalloped subcoronary implant. The complexity of the operation and concerns regarding autograft insufficiency have limited widespread adoption of the procedure. The subsequent use of…

Transcatheter Aortic Valve Replacement

◆ Transcatheter aortic valve replacement (TAVR) is a relatively new technique that has been clinically applied mostly in higher risk older patients in the past 10 years. Major differences in comparison to conventional aortic valve replacement (AVR) are as follows: ◆ Indirect visualization of the target by means of fluoroscopy, transesophageal echocardiography (TEE), and computed tomography (CT) ◆ Implantation of a specific transcatheter prosthesis consisting of…

Surgery of the Left Heart Valve Infective Endocarditis

Step 1 Pathogenesis, Pathology, and Microbiology of Left-Sided Infective Endocarditis ◆ Infective endocarditis (IE) is the most severe and devastating complication of heart valve disease, whether it is native valve endocarditis (NVE), prosthetic valve endocarditis (PVE), or infection on another cardiac device. Despite advances in surgical technique, operations for IE remain associated with the highest mortality of any valve disease. ◆ IE patients require a multispecialty…

Bentall Procedure

◆ In 1968, Bentall and De Bono described a technique for composite aortic valve and root replacement with reimplantation of the coronary arteries. The coronary arteries were sewn to the graft as a side-to-side anastomosis, and the aneurysm wall was wrapped around the graft. ◆ During the ensuing years, this technique underwent various modifications, primarily because of pseudoaneurysm formation at the side-to-side anastomosis of the coronary…

Aortic Valve-Sparing Operations

Step 1 Surgical Anatomy of the Aortic Root ◆ The aortic root is the anatomic segment between the left ventricle and ascending aorta. From the surgical viewpoint, it consists of the aortic annulus (AA), aortic cusps, aortic sinuses, and sinotubular junction (STJ). Although the term aortic annulus may be anatomically incorrect, it is often used in surgical anatomy and pathology to describe the aortoventricular junction. Approximately…

Aortic Valve Repair

Step 1 Introductory Considerations ◆ Aortic valve repair (AVr) has been shown to have a lower rate of valve-related complications compared to aortic valve replacement (AVR). ◆ It is especially beneficial for those in the younger age group due to a higher rate of bioprosthetic degeneration in the case of AVR and the cumulative risk of thromboembolism and bleeding in mechanical aortic valves. Step 2 Surgical…