Cardiac Surgery: A Complete Guide

Preface
Contents
Part I: Perioperative Care and Cardiopulmonary Bypass
1: Cardiac Catheterization
History of Cardiac Catheterization
Invasive Diagnostic Coronary Angiography
Indications
Pre-procedure Preparation
Technical Aspects of the Procedure
Access
Pharmacology
Catheter Selection and Manipulation
Angiographic Views
Post-procedure Care
Sheath Removal and Closure Devices
Coronary Angiogram Analysis
Complications
Right Heart Catheterization
Indications
Procedure
Complications
Interpreting Haemodynamics
Right Atrium
Right Ventricle
Pulmonary Artery
Pulmonary Capillary Wedge Pressure
Conclusion
References
2: Fractional Flow Reserve
Introduction
Definitions
How Was This Cut-Off Decided?
FFR Compared to Other Non-invasive Diagnostic Techniques
Limitations of Pressure Wire Measurements
Intravascular Ultrasound and FFR
Assessing Left Main Stem Stenosis Using FFR
FFR Use Pre Coronary Artery Bypass Grafting
Main Outcome Studies with FFR
DEFER Trial [24]
FAME Trial [9]
FAME 2 Trial [10]
COMPARE ACUTE Trial [27]
Instantaneous Wave-Free Pressure Ratio (iFR)
Conclusions
References
3: Echocardiography
Introduction
Essential Ultrasound Theory for Echocardiography
Modalities of Echocardiography
Assessment of Myocardial Function
Left Ventricular Systolic Function
Changes in Volumes/Dimensions
Indices of Global Contractility
Systolic Strain
Regional Contractile Function
Right Ventricular Systolic Function
Diastolic Function
Assessment of Valve Pathology
Aortic Stenosis
Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
Tricuspid Valve Assessment
Pulmonary Valve Assessment
Infective Endocarditis
Echo Findings in Endocarditis
Pericardial Disease
Masses
Contrast Echocardiography
Stress Echocardiography
Stress Echo for Coronary Artery Disease
Stress Echo for Aortic Stenosis
Stress Echo for Mitral Regurgitation
Other Indications for Stress Echocardiography
Transesophageal Echocardiography (TEE)
Pre-operative TEE
Intraoperative TEE
Conclusions
References
4: Cardiac Computed Tomography and Magnetic Resonance Imaging
Introduction
Technology
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Clinical Applications of CT and MRI
Coronary Artery Disease
Myocardial Ischaemia
Myocardial Viability
Heart Failure and Cardiomyopathies
Valvular Heart Disease
Congenital Heart Disease
Pericardial Diseases
Cardiac Tumours
Aortic Diseases
Post-surgical Patient
Conclusion
References
5: Assessment of Myocardial Viability
Introduction
Assessment of Myocardial Viability
Electrocardiogram (ECG)
Baseline 2D Echocardiography
Dobutamine Stress Echocardiography
Single Photon Emission Computerized Tomography (SPECT)
Positron Emission Tomography (PET)
Cardiac Magnetic Resonance Imaging (CMR)
Miscellaneous
Choice of Viability Test
Clinical Implications of Viability Status in Ischemic Cardiomyopathy
Coronary Revascularization in Ischemic Cardiomyopathy
Conclusions
References
6: Blood Conservation Strategies in Cardiac Surgery
Introduction
Pillar One: Optimization of Red Cell Mass and Erythropoiesis Prior to Surgery
Pillar Two: Minimize Blood Loss
Preoperative
Intraoperative
Postoperative
Pillar Three: Maximize the Ability of the Patient to Cope with Haematological Irregularities During Recovery Period by Optimizing Tolerance to Anaemia
Conclusion
References
7: Inotropes, Vasopressors and Vasodilators
The Case for Inotropic Support in Cardiac Surgery
What Are We Treating and What Are the Practical Dilemmas?
Ventricular Dysfunction
Circulatory Volume Status and Ventricular Preload
Vascular Resistances and Vasoplegia
Principles of Vasoactive Support
Clinical Classification of Haemodynamically Active Pharmacological Agents
Description and Clinical Utility of Inotropes and Vasoactive Agents
Sympathomimetic Drugs
Epinephrine (Adrenaline)
Norepinephrine (Noradrenaline)
Dopamine
Dobutamine
Phosphodiesterase-Type III Inhibitors
Levosimendan
Vasopressin
Special Focus on the Pulmonary Circulation
The Nitric Oxide (NO) Pathway
Phosphodiesterase-Type V Inhibitors
Prostacyclin Pathway
Inhaled Epoprostenol
Inhaled Iloprost
Special Cardiac Surgical Settings
Coronary Artery Bypass Graft Surgery
Acute on Chronic Heart Failure
LV Hypertrophy/Severe Diastolic Dysfunction
Valvular Surgery
Orthotopic Cardiac Transplantation
Right Ventricular Dysfunction
The Limits of Inotropic Support, Transition to Mechanical Circulatory Support
Conclusion
References
8: Cardiac Pacing in Adults
Introduction
Anatomy and Physiology of the Conduction System
Indications for Pacing and Defibrillators
Basic Principles of Pacing
Commonly Used Terms
Threshold
Sensitivity
Implantation Techniques
Common Complications and Problems with Devices
Novel Device Approaches
His Bundle Pacing
Leadless Pacing
Subcutaneous ICDs
WiSE CRT
Perioperative Management of Devices
MRI and Pacing
Pacing in the Peri- and Post-operative Setting
Peri-operative and Post-operative Pacing in Cardiac Surgery
Troubleshooting Temporary Epicardial Systems
Transitioning to Permanent Pacing in the Post-operative Period
Cardiothoracic Surgeon Involvement in Pacing Procedures
Surgical Lead Implantation
Lead Extraction
Conclusion
References
9: Adult Cardiopulmonary Bypass
Introduction
Cannulation Strategies
Key Elements of the Cardiopulmonary Bypass Machine
Monitoring
Temperature and pH Regulation
Cardioplegia
Pathophysiology of Cardiopulmonary Bypass
Conclusions
References
10: Myocardial Protection in Adults
Introduction
Myocardial Injury After Cardiopulmonary Bypass
Myocardial Protection
Hypothermic Methods of Cardioplegic Protection
Normothermic Methods of Cardioplegic Protection
Cardioplegic Solutions
Routes of Administration
Cardioplegia Composition and Timing of Delivery
Conclusion
References
11: Heparin-Induced Thrombocytopenia
Introduction
Pathogenesis
Timing
Clinical Picture
Frequency
Diagnosis
Treatment
Management of HIT in Cardiac Surgery
Bivalirudin in Cardiac Surgery
UFH and Platelet Inhibitors in Cardiac Surgery
Plasmapheresis Before Cardiac Surgery
HIT in Children
Conclusion
References
12: Tissue Sealants in Cardiac Surgery
Introduction
Definitions and Classification of Topical Hemostatic Agents, Tissue Sealants, and Adhesives
Clinical Use in Cardiovascular Surgery
Fibrin Sealants
Advantages
Disadvantages
Polyethylene Glycol Polymers
Advantages
Disadvantages
Albumin and Glutaraldehyde
Advantages
Disadvantages
Cyanoacrylates
Advantages
Disadvantages
Thrombin Gelatin Matrix
Advantages
Disadvantages
Cost Analysis at the Montreal Heart Institute
Conclusion
References
Part II: Coronary Artery Disease
13: Conduits for Coronary Artery Bypass Surgery
Introduction
Internal Thoracic Artery
The Radial Artery
The Right Gastroepiploic Artery
The Saphenous Vein
Grafting Strategy and Conduit Choice
References
14: Endoscopic Saphenous Vein and Radial Artery Harvesting
Introduction
Evidence
Graft Quality, Graft Occlusion and Major Cardiac-Related Events
Wound and Neurological Complications and Patients’ Satisfaction
Patient Selection
Surgical Technique
Surgical Equipment
Endoscopic Radial Artery Harvesting
First Step: Exposure of the Radial Artery
Second Step: Endoscopic Harvesting
Final Step: Radial Artery Retrieval
Endoscopic Saphenous Vein Harvesting
First Step: Exposure of the Great Saphenous Vein
Second Step: Endoscopic Harvesting
Final Step: Saphenous Vein Retrieval
Conclusion
References
15: Conventional Coronary Artery Bypass Grafting
Introduction
History of Coronary Artery Bypass Surgery
Indications for CABG
Conduct of the Operation (Table 15.2)
Incision
Division of the Pericardium
Cannulation
Aortic
Venous
Initiation of Cardiopulmonary Bypass
Target Identification and Preparation
Arteriotomy
Distal Anastomoses
Graft Configurations
Proximal Anastomoses
De-Airing and Cross Clamp Removal
Decannulation
Sternal Closure
Outcomes
Hospital Mortality
Hospital Morbidity
Antiplatelet Therapy
Conclusion
References
Additional Resources
Online
Books
16: Off-Pump Coronary Artery Bypass Grafting
Introduction
Evolution
Technique
Anesthetic Considerations
Indications
Contraindications
Outcomes
Concerns
Controversies
Conclusion
References
17: Minimally Invasive Coronary Artery Bypass Grafting
Introduction
Published Literature
Technique
Conclusion
References
18: Totally Endoscopic Coronary Artery Bypass Grafting
Introduction
Arrested Heart TECAB
Anesthetic Considerations
Cardiopulmonary Bypass and Myocardial Protection
Surgical Procedure
Beating Heart TECAB
Hybrid Revascularization
Learning Curve
Outcomes
Conclusion
References
19: Redo Coronary Artery Bypass Grafting
Introduction
Recent Trends
Indications
Technical Considerations
Sternal Re-entry
Dissection of the Heart, Ascending Aorta and Grafts
Alternative Approaches to Repeat Median Sternotomy
Cardioprotection
Grafting Pattern and Selection of Conduits
Surgical Outcomes
PCI vs CABG for Repeat Revascularization
Off-Pump vs On-Pump Redo CABG
Summary
References
20: Hybrid Coronary Revascularization
Introduction
Hybrid Coronary Revascularization
Rationale for HCR
Patient Selection
Surgical Approaches
MIDCAB
Robotic Approaches
Technique
Timing of Interventions
Results
Conclusions
References
21: Bilateral Internal Mammary Artery Grafting
Introduction
Historical Aspects
Rationale
Technical Aspects
Retroaortic In-Situ Right IMA Via Transverse Sinus to Circumflex Marginal Branches with In-Situ Left IMA to LAD
Retrosternal Crossover In-Situ Right IMA to LAD with In-Situ Left IMA to Circumflex Marginal Branches
Composite Left IMA-Right IMA T or Y Grafting
Right Internal Mammary Artery for Grafting the Right Coronary System
Clinical Outcomes
Evidence from Observational Studies
Evidence from Arterial Revascularization Trial
Concerns
Conclusion
References
22: Total and Multiple Arterial Revascularization
Introduction and Rationale for Arterial Coronary Grafting
Arterial Coronary Grafts
Left Internal Thoracic Artery (LITA)
Right Internal Thoracic Artery (RITA)
Radial Artery (RA)
Right Gastroepiploic Artery (RGEA)
Other Arterial Grafts
Deployment Strategies to Achieve Total Arterial or Multiple Arterial Coronary Bypass Grafting
Bilateral Internal Thoracic Artery Grafts
LITA and Left Radial Artery Graft
LITA and Bilateral Radial Arteries
Arterial Graft Patency Rates
Clinical Results
Perioperative Results
Long-Term Results
Three Versus Two Arterial Grafts
Elderly
Gender
Diabetes
Chronic Renal Disease
Left Ventricular Dysfunction
Reoperations
Off-Pump and Anaortic Coronary Artery Bypass Grafting
Contraindications and Limitations of Total Arterial or Multiple Arterial Coronary Bypass Grafting
Role of Saphenous Vein Grafts
Controversies in Total Arterial and Multiple Arterial Coronary Bypass Grafting
Conclusion
References
23: Anastomotic Devices for Coronary Artery Surgery
Introduction
Proximal Anastomotic Devices
Heartstring Proximal Seal System
PAS-Port Proximal Anastomosis System
Distal Anastomotic Devices
C-Port Distal Anastomosis System
Others
Conclusions
References
24: Post-infarction Ventricular Septal Defect
Epidemiology, Natural and Clinical History
Therapeutic Strategies and Options
Surgical Techniques
General Considerations
Apical Septal Defect
Small Ventricular Septal Defect
Medium or Large Septal Defects
Concomitant Procedures
Postoperative Results and Prognosis
Conclusion
References
25: Ischemic Mitral Regurgitation
Epidemiology
Pathophysiology
Diagnosis and Assessment of Ischemic Mitral Regurgitation
Medical Therapy
Indications for Surgical Intervention
Mitral Valve Replacement
Mitral Valve Repair
Concomitant Coronary Bypass Grafting
Percutaneous Therapy
Leaflet Apposition Therapy (MitraClip)
Therapies to Address Annular Dilation (Carillon, Cardioband, Mitralign)
Transcatheter Mitral Valve Replacement
Future Directions
References
26: Post-infarction Ventricular Aneurysms
Introduction
Incidence
Pathophysiology
Clinical Features
Investigations
Electrocardiogram
Chest X-Ray
Echocardiography
Left Ventriculography
Computed Tomography
Magnetic Resonance Imaging
Management
Pseudoaneurysm
Surgery
Transcatheter Device Closure
True Aneurysm
Surgical Indications
Surgical Techniques
Plication
Cooley Technique
Stoney Technique
Jatene Technique
Dor Technique
McCarthy Technique
Outcomes
Conclusion
References
27: Coronary Endarterectomy
Introduction
History
Techniques
Indications
Anticoagulation Protocol
Safety of Coronary Endarterectomy
Unresolved Issues
Single or Multi-vessel Coronary Endarterectomy
Onlay-Patch Grafting Using the ITA
Off-Pump Coronary Artery Bypass Grafting and Coronary Endarterectomy
Alternative Procedures
Conclusions
References
28: Transmyocardial Laser Revascularization
Introduction
Mechanism for Clinical Efficacy
Devices
Operative Technique
Clinical Trials
TMR as Sole Therapy
TMR as an Adjunct to CABG
Percutaneous Myocardial Laser Revascularization
Conclusions
References
29: Gene Therapy for Coronary Artery Disease
Introduction
Clinical Gene Therapy—Past Lessons and Current Successes
Gene Delivery Vectors
Plasmids
Viruses
MicroRNA
Routes of Administration
Angiogenesis
Cardiac Cellular Reprogramming
Challenges in Cardiac Gene Therapy
Conclusion
References
30: Combined Carotid and Coronary Artery Disease
Introduction
Should Routine Carotid Artery Screening Be Performed Prior to Surgery?
Management of Concomitant Carotid and Coronary Artery Disease
Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting
Staged Carotid Endarterectomy and Coronary Artery Bypass Grafting
Role of Carotid Artery Stenting
References
31: Coronary Artery Aneurysms and Fistulas
Coronary Artery Aneurysms
Introduction
Classification
Risk Factors and Associations
Pathogenesis
Clinical Presentation
Diagnosis
Treatment
Coronary Artery Fistulas
Introduction
Classification
Epidemiology
Pathophysiology
Clinical Presentation
Natural History
Diagnosis
Management Guidelines
Treatment
References
Part III: Valvular Heart Disease
32: Mechanical Prosthetic Valves
Introduction
Current Indications and Patient Selection
Current Mechanical Valves
St. Jude Medical (St. Paul, MN)
CryoLife (Kennesaw, GA)
LivaNova (London, England)
Medtronic (Minneapolis, MN)
Future Directions
Conclusions
References
33: Stented Bioprosthetic Valves
Introduction
Stented Aortic Bioprosthetic Valves
Crown PRT™ Valve
Trifecta™ Valve
Magna Ease™ Valve
Mosaic Ultra™ Valve
Outcomes
Hemodynamic Performance
Durability
Stented Mitral Bioprosthetic Valves
PERIMOUNT Plus Mitral™ Valve
Mosaic Mitral™ Valve
Outcomes
Hemodynamic Performance
Durability
Conclusions
References
34: Bentall and Mini-Bentall Procedure
Introduction
Mini-Bentall Procedure
Mini-sternotomy
Cardiopulmonary Bypass
Aortic Root Exposure
The “French Cuff” Technique
Coronary Button Re-implantation
Distal Anastomosis
Hemi-Arch Replacement
Closure
Outcomes
Conclusion
References
35: Aortic Valve-Sparing Root Replacement
Introduction
Natural History
Pathophysiology
Connective Tissue Disorders
Indications and Patient Selection
Remodeling of the Aortic Root and Other Annuloplasty Techniques
The David Operation
Results
Conclusion
References
36: Aortic Valve Repair
Introduction
Aortic Root Anatomy
Functional Aortic Annulus
Indications for Aortic Valve Repair
Assessment of Aortic Valve and the Repair-Oriented Classification
Surgical Techniques
Valve Exposure and Assessment
Restoration of the Functional Aortic Annulus
Subcommissural Annuloplasty
Valve-Sparing Root Replacement: Reimplantation Technique
Aortic Valve Annuloplasty
Cusp Repair Techniques
Bicuspid Valve Repair
Outcomes
Outcomes for Overall Population
Outcomes for Aortic Valve-Sparing Root Replacement
Outcomes for Bicuspid Aortic Valve Repair
Conclusion
References
37: The Small Aortic Root
Introduction
Relevant Aortic Root Anatomy
Aortic Root Sizing
Mechanical Valves
Bioprosthetic Valves
Aortic Homograft
Pulmonary Autograft
Operations for Aortic Root Enlargement
Conclusion
References
38: The Ross Procedure
Introduction
Historical Perspective
Rationale
Results Following the Ross Procedure
Survival
Hemodynamics
Valve-Related Complications
Reoperation
Technical Considerations
Conclusion
References
39: Bicuspid Aortic Valve and Aortopathy
Introduction
Anatomy
Prevalence and Etiopathogenesis
Clinical Presentation
Diagnosis
Clinical Course and Complications
Valvular Complications
Aortopathy
Management
Aortic Root and Ascending Aorta Surgery
Indications in Patients with BAV Without Significant Aortic Valve Dysfunction
Indications for Aortic Replacement in Patients with BAV and Aortic Valve Dysfunction
Aortic Arch
Postoperative Surveillance
Summary
References
40: Mitral Valve Replacement
Introduction
Repair Versus Replacement
Valve Selection
Surgical Technique of Mitral Valve Replacement
Postoperative Management
Future Directions
Conclusions
References
41: Techniques for Mitral Valve Repair
Introduction
Patient Selection and Pre-operative Work-Up
Surgical Approaches
Sternotomy
Robotic Approach
Anterolateral Right Mini-thoracotomy Approach
Mitral Valve Repair Techniques
Triangular Resection
Quadrangular Resection with Sliding Repair
Neochordae Implantation
Annuloplasty
Assessment of Repair
Published Outcomes
Conclusion
References
42: Mitral Valve Repair in Rheumatic Mitral Disease
Introduction
Problem and Burden of Rheumatic Valve Disease
Mitral Valve Complex: Structure and Dynamics
Rheumatic Mitral Valve Repair: Current Approaches and Strategy
Commissure
Mitral Leaflets
Chordae and Papillary Muscles
Annulus
Associated Problems
Tricuspid Regurgitation
Associated Aortic Valve Disease
Valvular Atrial Fibrillation
The Technique of Rheumatic Mitral Valve Repair
Exposure
Valve Analysis
Sequence of Rheumatic Mitral Repair
Results
Conclusion
References
43: Native Valve Endocarditis
Introduction
Relevant Anatomy
The Decision to Operate
Congestive Heart Failure
Para-annular Extension
Systemic Embolization
General Surgical Principles in Endocarditis Surgery
Reconstruction
Mitral Valve
Aortic Valve and the Aortomitral Curtain
Conclusion
References
44: Prosthetic Valve Endocarditis
Introduction
Imaging
Medical Management
Surgical Management
Prosthetic Aortic Valve Endocarditis
Is There Any Advantage of a Homograft Versus Conventional Mechanical or Biological Prostheses?
How Do We Approach an Aortic Perivalvular Abscess or Fistula?
How Do We Approach an Aortic Root Abscess that Has Destroyed the Aorto-Mitral Continuity?
What Is on the Horizon?
Mitral and Tricuspid Prosthetic Valve Endocarditis
Prosthetic Valve Endocarditis of Aortic Graft
Conclusion
References
45: Tricuspid Valve Surgery
Introduction
Indications for Tricuspid Surgery
Surgical Techniques for Tricuspid Valve Surgery
General Considerations
Tricuspid Valve Repair
Annuloplasty Techniques
Leaflet Repair Techniques
Other Surgical Techniques
Tricuspid Valve Replacement
Results of Surgical Techniques
Conclusion
References
46: Minimally Invasive Aortic Valve Surgery
Introduction
Definition, Surgical Approaches and Rationale for MIAVS
Preoperative Anaesthetic Considerations
Ministernotomy and Right Anterior Minithoracotomy
Criticism
MIAVR with Sutureless Valves
Conclusions
References
47: Minimally Invasive Mitral Valve Surgery
Introduction
Brief History
Definition
Patient Selection
Preoperative Screening
Operative Management
Surgical Setup
MV Repair Techniques
Triangular Resection
Quadrangular Resection with Sliding Plasty
Neochordae Implantation
Alfieri Stitch
Annuloplasty
Short- and Long-Term Results
Advantages, Disadvantages and Complications
The Future
References
48: Transcatheter Aortic Valve Therapies
Introduction
History of Transcatheter Aortic Valve Implantation (TAVI)
The Heart Team Approach
Risk Assessment
Latest Generation Transcatheter Valves
SAPIEN 3
Evolut R
Access Routes
Landmark TAVI Trials
Prohibitive Risk
High Risk
Intermediate Risk
Low Risk
TAVI Indications and Guideline Recommendations
Current Challenges
Permanent Pacemaker
Stroke
Valve Thrombosis and Antithrombotic Management
Conclusion
References
49: Transcatheter Pulmonary Valve Replacement
Introduction
Indications and Patient Selection
Current Technologies
Medtronic Melody Transcatheter Pulmonary Valve
Edwards SAPIEN Transcatheter Heart Valve
The Procedure and Technical Considerations
Hemodynamic and Clinical Outcomes
Complications
The Future
References
50: Transcatheter Mitral Valve Therapies
Introduction
Current Transcatheter Management of Mitral Regurgitation
Percutaneous Leaflet Repair
Percutaneous Chordal Approach
Percutaneous Mitral Annuloplasty
Transcatheter MV Implantation
Conclusion
References
51: Carcinoid Heart Disease
Introduction
Pathology and Pathophysiology
Clinical Presentation and Indications for Surgery
Perioperative Management
Surgical Considerations
Operative Approach
Choice of Prosthetic Valves
Left-Sided Heart Disease
Postoperative Surveillance
Outcomes of Valve Replacement for Carcinoid Heart Disease
Perioperative Mortality
Overall Survival and Functional Outcomes
Conclusion
References
Part IV: Thoracic Aorta
52: Acute Type A Aortic Dissection
Introduction
Clinical Presentation
Diagnostic Testing
Pathology and Classification
Surgical Technique
Arch Repair Options
Aortic Root Repair Options
Conventional and Frozen Elephant Trunk and Related Techniques
Complications and Surveillance
Conclusion
References
53: Acute Type B Aortic Dissection
Introduction
Nomenclature
Demographics, Etiology and Risk Factors
Clinical Presentation and Diagnosis
Management
Uncomplicated Acute and Subacute Type B Dissection
Complicated Acute Type B Aortic Dissection (ATBAD)
Chronic Type B Aortic Dissection (CTBAD)
Penetrating Aortic Ulcer and Intramural Hematoma
Follow-Up
Conclusions and Future
References
54: Chronic Type B Aortic Dissection
Introduction
Imaging
Best Medical Treatment
Indications for Intervention
Invasive Treatment
Open Surgical Repair
Endovascular Repair
Considerations
False Lumen Deployment
Stent Graft Induced New Entry (SINE)
Adherence to Medical Therapy
Level of Exercise
Quality of Life (QOL)
References
55: Aortic Intramural Hematoma and Penetrating Aortic Ulcer
Introduction
Pathophysiology
Epidemiology
Clinical Features
Diagnosis
Treatment, Outcomes and Prognosis
Medical Management
Open Surgical Repair
Endovascular Repair
Conclusion
References
56: Descending Thoracic and Thoracoabdominal Aortic Aneurysms
Introduction
Etiology
Epidemiology, Clinical Presentation and Natural History
Diagnosis of DTAA and TAAA
Treatment Options
Medical
Endovascular Treatment
Open Surgical Treatment
Preoperative Planning and Set-Up
Cerebrospinal Fluid Drainage
Incision
Cardiopulmonary Bypass
Cannulation Techniques
Partial Cardiopulmonary Bypass (Distal Aortic Perfusion)
Partial Left Heart Bypass (Distal Aortic Perfusion)
Full Cardiopulmonary Bypass
Deep Hypothermic Circulatory Arrest
TAAA Repair Technique
Outcomes After Open Repair of DTAA and TAAA
Conclusions
References
57: Aortic Arch Aneurysms
Introduction
Anatomy
Aortic Arch Pathology
Clinical Presentation
Imaging
Treatment
Criteria for Surgical Intervention
Perfusion and Cerebral Protection
Deep Hypothermic Circulatory Arrest (DHCA)
Retrograde Cerebral Perfusion (RCP)
Anterograde Cerebral Perfusion (ACP)
Surgical Repair Techniques
Conclusion
References
58: Hybrid Aortic Arch Repair
Introduction
Indications and Patient Selection
Operative Technique
Clinical Outcomes
Conclusion
References
59: Endovascular Stent Grafting of Thoracic Aorta
Introduction
Preoperative Planning and Considerations
Aortic Arch Landing Zones
Cerebrospinal Fluid Drainage
Neuromonitoring
Vascular Access
TEVAR for Descending Thoracic and Thoracic Abdominal Aneurysms
Open Debranching and TEVAR (Hybrid Aortic Repair)
Branched and Fenestrated Grafts for TEVAR
TEVAR for Acute Thoracic Aortic Dissection
Uncomplicated Type B Dissection
Complicated Type B Dissection
TEVAR in Blunt Traumatic Aortic Injury
Complications After TEVAR
Endoleaks
Vascular Access Injury
Neurologic Complications
Retrograde Dissection
Conclusions
References
60: Neuroprotective Strategies During Aortic Surgery
Spinal Cord Injury Following Thoracoabdominal Aortic Surgery
Pathophysiology
Identifying Patients at High-Risk
Protective Strategies
Cerebrospinal Fluid Drainage
Supporting Spinal Cord Perfusion Pressure (SCPP)
Hypothermia
Drugs
Preconditioning and Postconditioning
Monitoring
Brain Injury Following Ascending Aorta and Arch Surgery
Pathophysiology
Identifying Patients at High Risk
Protective Strategies
Hypothermia
Anterograde Cerebral Perfusion (ACP)
Retrograde Cerebral Perfusion (RCP)
Drugs
Topical Head Cooling
Acid-Base
Hematocrit
Monitoring
References
61: Sinus of Valsalva Aneurysms
Introduction
Embryology
Pathogenesis
Epidemiology
Clinical Features
Diagnostic Imaging
Management
Medical Management
Percutaneous Closure
Surgical Management
Conclusion
References
62: Elephant Trunk Procedures
Introduction
Evolution of the Elephant Trunk
Classification of Elephant Trunk Repairs
Preoperative Evaluation
Anesthetic Management
Cardiopulmonary Perfusion and Brain Protection
Operative Technique: First Stage Conventional Elephant Trunk
Operative Technique: Second Stage Conventional Elephant Trunk
Operative Technique: Frozen Elephant Trunk
Postoperative Surveillance
Outcomes
Conclusion
References
63: Porcelain Ascending Aorta
Introduction
Definition and Diagnosis
Pathogenesis and Associations
Atheromatous Aortic Disease: A Disease of the Tunica Intima
Non-atheromatous Aortic Disease: A Disease of the Tunica Media
Prevalence
PA and Cardiovascular Risk
PA and Cardiac Surgery
PA and TAVR
References
64: Cardiovascular Manifestations of Marfan and Loeys-Dietz Syndrome
Introduction
Proximal Aortic Disease in Marfan and Loeys-Dietz Syndrome
Acute Aortic Dissection in Marfan Patients
Interventions on the Distal Aorta After Type A Dissection
Aortic Dissection in Patients with Loeys-Dietz Syndrome
Mitral Valve Disease in Marfan and Loeys-Dietz Patients
Cardiomyopathy in Marfan and Loeys-Dietz Patients
Aneurysms of the Head and Neck Vessels in Loeys-Dietz Patients
Conclusion
References
Part V: Mechanical Circulatory Support and Transplantation
65: Pharmacologic Support of the Failing Heart
Introduction
Heart Failure with Reduced Ejection Fraction (HFrEF)
Drugs Which Prolong Survival
Drugs Which Do Not Prolong Survival but Improve the Symptoms
Heart Failure with Preserved Ejection Fraction (HFpEF)
Advanced Heart Failure
Acute Heart Failure (AHF)
Conclusion
References
66: Cardiac Resynchronization Therapy for Heart Failure
Introduction
What Is CRT?
How Does CRT Work?
CRT Trials
Indications and Patient Selection
Technical Considerations
Venous Access
Cannulation of the Coronary Sinus
Coronary Sinus Venogram
LV Lead Position
Post Implantation
Device Programming
Complications
The Future
References
67: Intra-aortic Balloon Pump
Introduction
Mechanism of Action
Indications for Use
Contraindications for Use
Technique of Insertion and Operation
Femoral Artery Insertion
Axillary Artery Insertion
Complications
Systemic Anticoagulation
Common Problems and Troubleshooting Measures
Poorly Synchronized Timing
Early Balloon Inflation
Late Balloon Inflation
Early Balloon Deflation
Late Balloon Deflation
Poor Diastolic Augmentation Despite Appropriate Timing
Limb Ischemia
Console Problems
Weaning from IABP
Conclusion
References
68: Extracorporeal Life Support in the Adult
Introduction
Circuit Configurations and Components
Respiratory Support
Hypoxemic Respiratory Failure, Acute Respiratory Distress Syndrome, and Recent Clinical Trials
Hypercapnic Respiratory Failure and Extracorporeal Carbon Dioxide Removal
Bridge to Lung Transplantation and Primary Graft Dysfunction
Cardiac Support
Extracorporeal Cardiopulmonary Resuscitation
Relative Contraindications and Complications
Long-Term Outcomes
Conclusion
References
69: Temporary Circulatory Support Devices
Introduction
Indications for Temporary MCS
Patient Selection
Options for Temporary MCS
Impella®
TandemHeart™
CentriMag™
Post-operative Management and Weaning
Conclusions
References
70: Heart Transplantation
Introduction
Indications and Patient Selection
Recipient Criteria
Donor Criteria
Organ Allocation
Procedure and Technical Considerations
Organ Retrieval
Organ Implantation
Haemodynamic and Clinical Outcomes
Complications
Primary Graft Dysfunction
Acute Rejection
Cardiac Allograft Vasculopathy
Malignancy
The Future
References
71: Heart-Lung Transplantation
Introduction
History
Indications for Heart-Lung Transplantation
Eisenmenger Syndrome
Uncorrectable Congenital Heart Disease with Atresia or Hypoplasia of the Pulmonary Arteries
Combined Cardiac and Pulmonary Disease
Selection Criteria for Heart-Lung Transplantation
Recipient Age
Aortopulmonary Collaterals
Previous Thoracic Surgery
Technique of Heart-Lung Transplantation
The Donor Procedure
The Recipient Procedure
Postoperative Management
Immunosuppression
Complications
Acute Rejection
Airway Complications
Chronic Lung Allograft Dysfunction
Cardiac Allograft Vasculopathy
Graft-Versus-Host Disease
Survival After Heart-Lung Transplantation
References
72: Immunosuppression in Cardiac Transplantation
Introduction
Goal of Immunosuppression
Medications for Desensitization Prior to Transplantation
Induction and Maintenance Therapies
Induction Therapy
Maintenance Therapy
Specific Immunosuppression Medications
Glucocorticoids
Antiproliferatives
Azathioprine
Mycophenolic Acid
Calcineurin Inhibitors
Proliferation Signal Inhibitors
Which Regimen Is Superior?
Standard Triple Therapy
Corticosteroid Withdrawal
Renal Sparing
Drug-Drug Interactions
Medications for Rejection
Rejection
Endomyocardial Biopsy (EMBx) and Non-invasive Methods to Screen for Rejection
Acute Cellular Rejection
Antibody Mediated Rejection
Cardiac Allograft Vasculopathy
Future Directions
References
73: Complications of Heart Transplantation
Introduction
Background
Early Complications
Primary Graft Dysfunction (PGD) or Primary Graft Failure (PGF)
Pulmonary Hypertension and Right Ventricular Dysfunction
Rejection
Non-cytomegalovirus Infections
Cytomegalovirus Infections
Surgical Complications
Acute Kidney Injury (AKI) Requiring Haemofiltration
Late Complications
Renal Dysfunction
Cardiac Allograft Vasculopathy (CAV)
Malignancy
Other Chronic Complications
Conclusion
References
Part VI: Miscellaneous Cardiovascular Disorders
74: Cardiac Tumors
Incidence
Classification
Clinical Symptoms
Reactive Cardiac Masses and Pseudotumors
Mural Thrombi
Calcifying Amorphous Pseudotumor
Mesothelial Pseudotumors
Ectopias
Cystic Tumor of the Atrioventricular Node
Germ Cell Tumors of the Heart
Benign Neoplasms
Papillary Fibroelastoma
Rhabdomyoma
Adult Cellular Rhabdomyoma
Lipomatous Hypertrophy of the Atrial Septum
Cardiac Lipoma
Cardiac Fibroma
Cardiac Myxoma
Malignant Tumors
Primary Cardiac Sarcomas
Angiosarcoma
Undifferentiated Pleomorphic Sarcomas (Malignant Fibrous Histiocytoma)
Leiomyosarcoma
Rhabdomyosarcoma
Cardiac Lymphoma
Conclusion
References
75: Concomitant Coronary Artery Disease and Lung Cancer
Introduction
Concomitant or Staged Procedure
Impact of Adhesions on Staged Procedure
Use of Extracorporeal Circulation
Off-Pump Coronary Artery Bypass Grafting
Choice of Incision for Access
Extent of Pulmonary Resection
Conclusions
References
76: Trauma to the Heart and Great Vessels
Introduction
Initial Evaluation
Evaluation and Management per Structure Injured
Heart
Surgical Approach
Penetrating Cardiac Injury
Coronary Artery Injury
Blunt Cardiac Injury
Aorta
Penetrating Aortic Injury
Blunt Aortic Injury
Innominate Artery
Penetrating Innominate Artery Injury
Blunt Innominate Artery Injury
Carotid Artery
Penetrating Carotid Artery Injury
Blunt Carotid Artery Injury
Subclavian Artery
Conclusion
References
77: Pericardial Diseases
Anatomy and Functions of Pericardium
Etiology of Pericardial Diseases
Chronic Relapsing (Recurrent) Pericarditis
Effusive Pericardial Disease
Constrictive Pericardial Disease
Pericardiectomy
Indications
Approaches
Use of Cardiopulmonary Bypass
Technique
Special Considerations
Results of Pericardiectomy
Conclusion
References
78 Pulmonary Thromboendarterectomy
Introduction
Indications
Operation Principles
Technical Aspects
Surgical Advancements
Results
Mortality Rate
Other Post-operative Complications
Conclusion
References
79: Surgical Management of Atrial Fibrillation
Background
Pathology
Patients and Workup
Procedures
Surgical Rhythm Control
The Cox-Maze Procedures
Less Extensive Lesion Sets
The Hybrid Approach
Left Atrial Appendage Exclusion
Conclusion
References
80: Hypertrophic Cardiomyopathy
Introduction
Surgical Treatment
Preoperative Evaluation
Operative Methods
Postoperative Management
Perioperative Results
Long-Term Outcomes
References
81: Left Ventricular Volume Reduction
Introduction
Rationale for Left Ventricular Volume Reduction
Volume-Related or Shape-Related Left Ventricular Reduction
Secondary Mitral Regurgitation
The STICH Trial
Clinical Results
Conclusions
References
82: Renal Failure After Cardiac Surgery
Introduction
Defining Cardiac Surgery Associated Acute Kidney Injury
Pathogenesis of Cardiac Surgery Associated Acute Kidney Injury
Risk Factors and Prediction of Cardiac Surgery Associated Acute Kidney Injury
Renal Protective Strategies
Preoperative Strategies
Optimization of Renal Function
Aspirin
Statins
Erythropoietin
Intraoperative Strategies
Anemia Correction
Blood Glucose Control
Blood Management Program
Mini-CPB and Zero-Balanced Ultrafiltration
Surgical Strategies
Volatile Anesthesia
Remote Ischemic Preconditioning
Balanced Crystalloid Solutions
Fenoldopam
Natriuretic Peptide
Sodium Bicarbonate
Levosimendan
Dexmedetomidine
Vasopressin
Postoperative Strategies
KDIGO Bundle
Early Use of RRT
Extended Daily Dialysis
Early Detection of Acute Kidney Injury
The Role of Biomarkers
Conclusion
References
83: Bleeding and Re-exploration After Cardiac Surgery
Introduction
Risk Factors for Bleeding Associated with Cardiac Surgery
Medical Management of Postoperative Bleeding
Surgical Methods to Manage Postoperative Bleeding
Timing of Re-exploration
Reoperation Versus Transfusion
Intraoperative Approaches
Conclusion
References
84: Sternal Wound Infections
Introduction
Clinical Presentation
Pathogenesis
Incidence and Risk Factors
Treatment
Negative-Pressure Wound Therapy
Outcome of Treatment
Late Sternal Wound Infections
Preventive Measures
Conclusion
References
85: Atrioventricular Disruption
Introduction
Types
Pathogenesis and Risk Factors
Strategies to Minimize the Risk of Atrioventricular Disruption
Management
Conclusion
References
Part VII: Paediatric and Congenital Heart Disease
86: Pediatric Cardiopulmonary Bypass and Hypothermic Circulatory Arrest
Introduction
Conduct of Cardiopulmonary Bypass
Anticoagulation
Arterial Cannulation
Venous Cannulation
Femoral Cannulation
Initiation of Cardiopulmonary Bypass
Blood Flow Through the Cardiopulmonary Bypass Circuit
Pump Flow/Oxygen Delivery
Goal-Directed-Perfusion
Vents/Pump Suckers
Weaning from CPB
Deep Hypothermic Circulatory Arrest
Adult Versus Pediatric Cardiopulmonary Bypass
Modified Ultrafiltration
Conclusion
References
87: Myocardial Protection in Children
History of Cardioplegia
Differences Between Pediatric and Adult Hearts
Methods of Myocardial Protection
Hypothermia
Cardioplegia Administration Techniques
Protection Strategies in Pediatric Myocardium
References
88: Pediatric Extracorporeal Membrane Oxygenation and Mechanical Circulatory Assist Devices
Introduction
Pediatric Extracorporeal Membrane Oxygenation
Definition
Types
Indications and Contraindications
ECMO Circuit
Cannulation
ECMO Management
Complications
Clinical Outcomes
Translational Research for Optimization of Neonatal and Pediatric ECMO Circuitry
Summary
Pediatric Mechanical Circulatory Assist Devices
Short-Term Pediatric MCS
Devices
Outcomes and Complications
Long Term Pediatric MCS
Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs)
Devices and Patients
Survival Post-VAD Implantation
Adverse Events
Summary
References
89: Palliative Operations for Congenital Heart Disease
Introduction
Procedures to Decrease Pulmonary Blood Flow
Pulmonary Artery Banding
Banding of Main Pulmonary Artery
Indications
Technique
Complications
Banding of Branch Pulmonary Arteries
Procedures to Increase Pulmonary Blood Flow
Systemic-Pulmonary Shunts
Indications
Classic Blalock-Taussig Shunt
Modified Blalock-Taussig Shunt
Potts Shunt
Waterston Shunt
Central Shunt
Bidirectional Glenn Shunt
Right Ventricle-to-Pulmonary Artery Shunt (Sano Shunt)
Right Ventricular Outflow Tract Stenting
Ductal Stenting
Procedures to Enhance Mixing
Indications
Balloon Atrial Septostomy
Blalock-Hanlon Operation
Open Atrial Septectomy
Palliative Atrial Switch Operation
Other Miscellaneous Palliative Procedures
Hybrid Palliation
Indications
Technique
Complications
Conclusion
References
90: Coronary Anomalies in Children
Introduction
Anomalous Origin of Coronary Arteries
Anomalous Coronary Origin from the Pulmonary Artery
Anomalous Aortic Origin
Coronary Artery Fistula
Conclusion
References
91: Congenital Valvar and Supravalvar Aortic Stenosis
Congenital Aortic Valve Stenosis
Introduction
Anatomy
Pathophysiology
Clinical Features
Diagnosis
Electrocardiogram
Chest Radiograph
Echocardiogram
Cardiac Magnetic Resonance
Cardiopulmonary Exercise Testing
Cardiac Catheterization
Management of Critical Aortic Stenosis
Medical Management
Timing of Intervention
Surgical Intervention
Catheter Intervention
Hybrid Approach
Long-Term Outcomes
Management of Non-critical Aortic Stenosis
Medical Management
Timing of Intervention
Catheter Intervention
Surgical Intervention
Long-Term Outcomes
Supravalvar Aortic Stenosis
Introduction
Anatomy
Pathophysiology
Clinical Features
Investigations
Electrocardiogram
Chest Radiograph
Echocardiogram
Magnetic Resonance Imaging and Computed Tomography
Cardiac Catheterization
Management
Long-Term Outcomes
References
92: Atrial Septal Defects
Introduction
Clinical Features
Diagnosis
Echocardiogram
Transthoracic Echocardiogram (TTE)
Transesophageal Echocardiogram (TEE)
Intracardiac Echocardiogram (ICE)
Cross Sectional Imaging
Cardiac Catheterization
Indications and Timing for ASD Closure
Surgical Versus Transcatheter Management
Surgical and Interventional Therapy Recommendations
Surgical Techniques and Results
Traditional Surgical Closure
Minimally Invasive Cardiac Surgery
Right Axillary Incision Approach
Secundum ASD
Primum ASD
Sinus Venosus ASD
Warden Procedure
Postoperative Complications
Outcomes of Transcatheter Closure and Comparison with Surgical Closure
Catheter Closure of ASD Compared to Minimally Invasive Cardiac Surgery
Early Complications of ASD Devices
Late Complications of ASD Devices
Conclusion
References
93: Isolated Ventricular Septal Defect
Introduction
Epidemiology
Morphology
The Right Ventricle (RV)
The Left Ventricle (LV)
Perimembranous Ventricular Septal Defects
Muscular Ventricular Septal Defects
Juxta-Arterial Defects
Other
Pathophysiology
Clinical Features
Small VSD
Large Symptomatic VSD
Investigations
12-Lead Electrocardiography
Chest X-Ray
Echocardiography
Medical Management
Indications for Intervention
Closure of VSDs in the Context of High Pulmonary Vascular Resistance
Surgical Intervention
Standard Closure of Perimembranous VSD
Continuous Versus Interrupted Sutures
Doubly Committed VSD
Muscular VSDs
Special Circumstances
TV Apparatus Detachment
Aortic Insufficiency
Residual or Additional VSD
Pulmonary Artery Banding
New Approaches
Hybrid Approach to VSD Closure
Non-surgical Intervention
Transcatheter Device Closure of Muscular VSDs
Pacemaker Implantation After VSD Closure
Late Effects of Surgical Closure of Isolated VSD
Conclusion
References
94: Patent Ductus Arteriosus
Introduction
Embryology and Anatomy
Normal Physiologic Postnatal Closure
Patency with Pulmonary Overcirculation
Patency Without Overcirculation
Open Surgical Methods of Closure
Catheter Methods of Closure
Conclusion
References
95: Aortopulmonary Window
Introduction
Embryology
Classification
Associated Conditions
Pathophysiology
Clinical Features
Symptoms
Signs
Diagnosis
Natural History
Management
Medical and Interventional Therapy
Surgical
Indications
Technique of Operation
Postoperative Management
Results
Conclusion
References
96: Coarctation of the Aorta
Introduction
Morphology
Pathophysiology and Clinical Presentation
Fetal Presentation
Neonatal Presentation
Infant Presentation
Childhood/Adolescent/Adult Presentation
Diagnosis
Echocardiography
Computed Tomography Scanning
Magnetic Resonance Imaging
Catheterisation and Angiography
Initial Management
Definitive Treatment
Surgery for Coarctation in Neonates and Infants
Left Thoracotomy Without Cardiopulmonary Bypass
Surgical Technique
Specific Complications, Advantages, Disadvantages and Alternative Treatments
Median Sternotomy with Cardiopulmonary Bypass
Surgical Technique
Specific Complications, Advantages, Disadvantages and Alternative Treatments
Treatment of Coarctation in Older Children and Adults
Outcomes in Contemporary Practice
Long-Term Follow-Up
References
97: Pulmonary Valve Stenosis
Introduction
Anatomy and Spectrum of Lesions
Pathophysiology
Natural History
Clinical Manifestations
Symptoms
Signs
Diagnostic Evaluation
Indications for Treatment
Management
Surgical Techniques
Valvotomy and/or Valvectomy on Cardiopulmonary Bypass
Off-Pump Closed Valvotomy
Postoperative Management
References
98: Truncus Arteriosus
Introduction
Morphology
Classification
Natural History
Pathophysiology
Diagnosis
Treatment
Post-operative Management
Outcomes
Conclusion
References
99: Transposition of the Great Arteries
Introduction
Epidemiology
Physiology
Preoperative Imaging
Preoperative Management
Balloon Atrial Septostomy
Prostaglandin E1
Timing of Surgery
Surgical Techniques
Historical Perspective
Arterial Switch Operation
Presence of Outflow Tract Obstruction
Long-Term Follow Up
Conclusion
References
100: Congenitally Corrected Transposition of the Great Arteries
Introduction
Surgical Pathology
Ventricular Septal Defect
Left Ventricular Outflow Tract
Atrioventricular Valves
Coronary Arteries
Conduction System
Pathophysiology and Clinical Presentation
Diagnosis
Surgical Treatment
ccTGA with Isolated Left Ventricular Outflow Tract Obstruction
ccTGA with Pulmonary Stenosis/Atresia and Ventricular Septal Defect
ccTGA with Tricuspid Valvar Insufficiency
ccTGA with Isolated Ventricular Septal Defect
Alternative Procedures
Results
Summary
References
101: Tetralogy of Fallot
Introduction
Anatomy and Morphology
Pathophysiology
Approach to Surgical Decision Making in the Modern Surgical Era: Pulmonary Valve Preservation and the Scope of the Problem
Surgical Management
VSD Closure and RVOT Muscle Bundle Resection
Approach to the Pulmonary Valve
Surgical Options for Valve-Sparing TOF Repair
Mild-Moderate Pulmonary Stenosis and Mildly Dysplastic Valve
Moderate Pulmonary Valve Stenosis or Dysplasia
Commissurotomy and Intraoperative Balloon Pulmonary Valve Dilation
Valve-Sparing Transannular Reconstruction
Perioperative Management
Postoperative Outcomes
New York-Presbyterian Morgan Stanley Children’s Hospital/Columbia University Outcomes
Conclusions and Perspective
References
102: Hypoplastic Left Heart Syndrome
Introduction
Morphology and Clinical Implications
Neonatal Management and the Norwood Operation
Norwood Operation
Right Ventricle to Pulmonary Artery Conduit Versus the Blalock-Taussig Shunt
The ‘Hybrid’ Norwood
Outcomes
Second and Third Stage Procedures
Second Stage
Third Stage
Late Outcomes
Transplantation
Future
References
103: Congenital Aortic Arch Interruption and Hypoplasia
Introduction
Anatomy
Clinical Features
Diagnosis and Preoperative Management
Surgical Management
Postoperative Care
Results
Special Situations
Hypoplastic Aortic Arch
LVOT Obstruction
Conclusion
References
104: Pulmonary Atresia with Intact Septum
Introduction
Anatomy
Overview
Right Ventricle and Tricuspid Valve
Coronary Abnormalities
Pathophysiology
Blood Flow
Right Ventricular Dependent Coronary Circulation
Presentation and Diagnosis
Surgical Management
General Principles and Goals of Management
Stages of Surgery
Neonatal Management
Management After the Neonatal Period
Mild Right Ventricular Hypoplasia
Moderate Right Ventricular Hypoplasia
Severe Right Ventricular Hypoplasia
Outcomes
Conclusion
References
105: Complete Atrioventricular Septal Defect
Introduction
Anatomic Features and Nomenclature
Diagnosis
Indications and Timing for Repair
General Strategy for Surgical Repair
Technique of Nunn Repair
Outcome of Surgery
Conclusion
References
106: Double Outlet Right Ventricle
Introduction
Historical Perspective
Definition
Embryology
Genetics
Morphology
Ventricular Septal Defect
Subaortic VSD
Subpulmonic VSD
Non-committed VSD
Doubly Committed VSD
DORV Classification
Associated Anomalies [1, 5, 18]
Pathophysiology
Ventricular Septal Defect and Great Artery Relation
Patent Ductus Arteriosus
Pulmonary Vascular Resistance
Clinical Presentation
Physical Signs
Diagnosis
Management
Preoperative Management
Postoperative Management
Surgical Management
Outcomes
Conclusion
References
107: Neonatal Ebstein’s Anomaly
Introduction
Associated Anomalies and Arrhythmias
Anatomy of Ebstein’s Anomaly
Pathophysiology
Diagnostic Evaluation
Chest X-Ray
Electrocardiography
Echocardiography
Catherization/Computed Tomography/Magnetic Resonance Imaging
Treatment
Medical
Surgical Indications
Surgical Procedures
Outcomes
Conclusion
References
108: Vascular Rings and Pulmonary Artery Sling
Introduction
Vascular Rings
Natural History and Clinical Presentation
Diagnostic Techniques
Indications for Operation
Operative Techniques
Double Aortic Arch
Right Aortic Arch
Pulmonary Artery Sling
Clinical Presentation
Operative Techniques
Pulmonary Artery Sling Repair
Slide Tracheoplasty
Rare Vascular Rings
Conclusions
References
109: Congenital Left Ventricular Outflow Tract Obstruction
Introduction
Subvalvar Aortic Stenosis
Overview
Anatomy
Pathophysiology
Presentation, Diagnosis and Indications for Surgery
Surgical Management
Resection of Fibrous Shelf
Modified Konno Operation
Aortoventriculoplasty Procedures
Konno Operation
Ross-Konno Procedure
Outcomes
Supravalvar Aortic Stenosis
Overview
Anatomy
Pathophysiology
Presentation and Diagnosis
Indications for Surgery
Surgical Management
Surgery for Localised SVAS
Single-Patch (McGoon) Technique
Two-Patch Repair (Inverted Y-Shaped) Doty Technique
Three-Patch (Brom) Technique
Sliding Aortoplasty: Three-Sinus Repair (Myers-Waldhausen)
Surgery for Diffuse Supravalvar Aortic Stenosis
Outcomes
Conclusion
References
110: Pediatric Heart Transplantation
Introduction and Historical Note
Indications for Pediatric Heart Transplantation
Cardiomyopathy
Congenital Heart Disease
Cardiac Tumors
Recipient Evaluation
Anatomic Considerations
Pulmonary Vascular Resistance
The Sensitized Patient
The Pediatric Heart Donor
The Transplant Operation
Immunosuppression
Pre-transplant Immunosuppression
Maintenance Immunosuppression
Complications of Heart Transplantation
Allograft Rejection
Acute Cellular Rejection
Antibody-Mediated Rejection
Treatment of Acute Rejection
Outcomes
Infection
Malignancy
Allograft Vasculopathy
Survival
Retransplantation
Future Directions
References
Review Questions
Answers
Index