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Aortic Root Enlargement Techniques

Introduction ◆ Aortic valve replacement (AVR) is one of the most commonly performed operations in cardiac surgery. It is not only effective in alleviating symptoms in patients suffering from aortic valve disease, but also improves survival. However, in patients with a small aortic annulus, the benefits of this operation are dependent on the surgeon's ability to avoid patient-prosthesis mismatch (PPM). PPM was first described by Rahimtoola…

Minimally Invasive, Mini-Thoracotomy Aortic Valve Replacement

Step 1 Introductory Considerations ◆ Minimally invasive valve surgery has numerous benefits compared with a standard median sternotomy. These benefits include reduced surgical trauma, blood loss, transfusion requirements, and reoperations for bleeding. Ventilation times and intensive care unit and hospital lengths of stay are also reduced. Patients undergoing minimally invasive surgery also experience a more rapid return to functional capacity and less use of rehabilitative resources,…

Aortic Valve Replacement

Introductory Considerations Step 1 Surgical Anatomy ◆ The aortic valve is the last valve in the heart through which the blood is pumped before it goes to the body. The purpose of the aortic valve is to prevent backflow of blood from the aorta into the left ventricle. ◆ The normal aortic valve is tricuspid, with left coronary, right coronary, and noncoronary leaflets. Each leaflet is…

Postinfarction Ventricular Septal Defect Repair

Step 1 Surgical Anatomy ◆ Postinfarction ventricular septal defects (VSDs) are classified as occurring in three locations—apical, anterior, and posteroinferior ( Fig. 8.1 ). Most common is an anterior or apical defect caused by anterior septal myocardial infarction after occlusion of the left anterior descending coronary artery. In about one-third of patients, the rupture occurs in the posterior septum after an inferior septal infarction. The inferior…

Robotic Coronary Artery Bypass Grafting

Introductory Considerations ◆ The goal of any minimally invasive procedure is to achieve the least surgical trauma possible and to carry out the intervention in a port-only approach. After unsuccessful attempts to perform endoscopic coronary bypass surgery using long-shafted thoracoscopic instrumentation, the first totally endoscopic coronary bypass grafting (TECAB) was carried out in 1998 using a surgical robot. Since then, TECAB has been further developed from…

Minimally Invasive Coronary Artery Bypass Grafting

See Videos 5.1 to 5.10 on ExpertConsult.com . Minimally Invasive Cardiac Surgery–Coronary Artery Bypass Grafting (MICS CABG) ◆ This technique enables revascularization with a similar configuration as that in a sternotomy technique, using left internal thoracic artery (LITA) harvesting and hand-sewn proximal and distal anastomoses under direct visualization. Complete revascularization is achieved in 95% of cases, allowing access to the anterior, lateral, and inferior walls of…

Off-Pump Coronary Artery Bypass Grafting

◆ The ability to perform coronary artery bypass grafting (CABG) competently without the use of cardiopulmonary bypass is an important skill for all cardiac surgeons. There are cases in which a safe coronary revascularization procedure can only be performed as an off-pump procedure. Although off-pump coronary artery bypass (OPCAB) has a steeper learning curve than on-pump revascularization, there are clear benefits to it. ◆ After an…

On-Pump Coronary Artery Bypass Grafting

Step 1 Surgical Anatomy ◆ The named epicardial coronary arteries that serve as the distal anastomotic targets for coronary artery bypass grafting (CABG) are most commonly located just deep to the epicardial fat and superficial to the myocardium. The arteries, usually the left-sided vessels, may be located more deeply within the myocardium (intramyocardial). A straighter course on coronary angiography may suggest an intramyocardial location. ◆ The…

Cannulation Techniques for Cardiopulmonary Bypass

Step 1 Surgical Anatomy 1 Ascending Aorta ◆ Cannulation sites on the ascending aorta should be as high as safely possible. Surgeons today more frequently perform complete arterial revascularization, which in some cases may require delicate proximal anastomoses of arterial conduits (e.g., free internal thoracic arteries, radial arteries) directly to the aorta. These anastomoses are more difficult to construct if the aorta is under tension and…

Surgical Incisions

◆ The median sternotomy was reintroduced by Julian in 1957, which was already described by Milton in 1897. The median sternotomy has become a gold standard approach for cardiac procedures, with subsequent developments in cardiac surgery. The skin incision could be shortened caudally or cranially up to half the length of the sternum. This approach allows excellent access to every cardiac chamber and to vessels entering…

Abuse and factitial disorders

Child abuse Child abuse is a broad term used to describe a spectrum of nonaccidental trauma inflicted upon children. Kempe et al. are generally credited with emphasizing the prevalence and importance of this entity when they coined the term battered child syndrome in 1962. This “syndrome” has subsequently been expanded to include an array of childhood abuses, including physical abuse, sexual abuse, and neglect. Child abuse…

Skin signs of other systemic diseases

Primary immunodeficiency disorders Recurrent infections, including those involving the skin, raise the possibility that a child has an immune deficiency. The most common cause of immunodeficiency in children is acquired immunodeficiency resulting from human immunodeficiency virus (HIV) infection (see Chapter 15 ). Less commonly, children with evidence of an immunodeficiency have an inherited disorder. Genetic immunodeficiency disorders may show a variety of cutaneous abnormalities, some of…

Inborn errors of metabolism

The inborn disorders of metabolism are a group of primarily autosomal recessive hereditary disorders that result in metabolic and clinical defects. (More comprehensive discussion of some of these topics is covered elsewhere: disorders of tyrosine metabolism [Richner–Hanhart syndrome], Gaucher syndrome, and multiple sulfatase deficiency are mentioned in Chapter 5 ; Menkes syndrome in Chapter 7 ; alkaptonuria in Chapter 11 ; Fabry disease and fucosidosis in…

Endocrine disorders and the skin

Endocrinologic diseases often display cutaneous features that may provide diagnostic clues, and patients with these disorders may be more susceptible to a variety of mucocutaneous problems. Some of these conditions and their therapy, where applicable, are reviewed here. A thorough discussion of all endocrine disorders and their treatment is beyond the scope of this chapter. Thyroid disorders Patients with hyperthyroidism or hypothyroidism may show a variety…

Venoactive Drugs

Introduction Venoactive drugs (VAD) are a heterogeneous group of medicinal products, of plant or synthetic origin, which have effects on edema (C 3 ) or on symptoms related to chronic venous disease (CVD) (classes C 0s –C 6s according to the CEAP [clinical, etiology, anatomy and pathophysiology] classification). A specific ‘painkiller’ effect has been suggested, as VAD are active on venous pain, which does not respond…

Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light

The laser was first conceived in the imagination of H.G. Wells, who described the use of a light gun in 1896 as an outer-space weapon. Albert Einstein then transformed this vision into a theoretical possibility in the early 1900s. Einstein described the process of stimulated emission as an offshoot in his quest to show the inherent singular nature of the four basic forces of the universe.…

Clinical Methods for Sclerotherapy of Telangiectasias

Historical Review of Techniques Sclerosing treatment for telangiectasias was ignored until the 1930s, when Biegeleisen injected sclerosing agents intradermally or subcutaneously into the general area of capillary enlargement. However, this procedure caused severe necrosis and lacked effect on the telangiectasias. Biegeleisen then developed and popularized a method of ‘microinjection’ of telangiectasias with sclerosing agents through the use of an extremely fine metal needle (later described as…

Intravascular Approaches to the Treatment of Varicose Veins: Radiofrequency, Lasers and More

Introduction For nearly a century, open surgical treatment has been considered the gold standard to treat uncomplicated varicose veins. Since the early 1990s, however, techniques have shifted toward minimally invasive approaches. Foremost among these techniques are endovenous thermal ablation using radiofrequency and endovenous laser therapy. Multiple randomized clinical trials have now established the equivalent efficacy of both radiofrequency ablation (RFA) and endovenous laser therapy (EVLA) techniques…

Role of Surgery in the Treatment of Varicose Veins

Background Surgery for treating varicose veins (VVs) has been advocated for centuries. The first descriptions were attributed to Aulus Cornelius Celsus from the Roman era, which included hook extraction of varicose veins, double ligation and phlebectomy. Modern surgery is based on hemodynamic treatment, which started at the beginning of the nineteenth century when T. Rima performed a high ligation (HL) of the upper great saphenous vein…