Rovenstein created the first American clinic for the treatment of chronic pain purchase online bactrim antibiotics dairy, where he and his associates refined techniques of lytic and therapeutic injections and used the American Society of Regional Anesthesia to further the knowledge of pain management across the United States discount bactrim 480mg overnight delivery infection 2 levels. During his periods of military cheapest generic bactrim uk antibiotics dog bite, civilian, and university service at the University of Washington, Bonica formulated a series of improvements in the management of patients with chronic pain. His classic text The Management of Pain is regarded as a standard of the literature of anesthesia. These attempts generally failed until German surgeon Ludwig Rehn repaired a right ventricular stab wound in September 1896. The taboo of cardiac surgery was summarized by Theodore Billroth when he supposedly said “any surgeon who would attempt an operation on the heart should lose the respect of his colleagues. Fortunately, the turn of the 20th century saw many advances in anesthesia practice, blood typing and transfusion, anticoagulation, and antibiosis as well as surgical instrumentation and technique. Some continued to attempt procedures like closed mitral valvotomy in the midst of these technologic advancements, but outcomes were still very poor with mortality rates exceeding 80%. Many believe that the successful ligation of a 7-year-old girl’s patent ductus arteriosus by Robert Gross in 1938 served as the landmark case for modern cardiac surgery. Soon after Gross’ achievement, a host of new procedures were developed for repairing congenital cardiac lesions, including the first Blalock–Taussig shunt performed on a 15-month-old “blue baby” in 1944. Although the shunt had been successfully demonstrated in animal68 models, Austin Lamont, Chief of Anesthesia at Johns Hopkins, was not supportive of the procedure. He emphatically stated “I will not put that child to death” and left the open drop ether–oxygen anesthetic to resident anesthesiologist Merel Harmel. Together, Harmel and Lamont116 would publish the first article on anesthesia for cardiac surgery in 1946 based on 100 cases with Alfred Blalock and repair of congenital pulmonic stenosis. Closed cardiac surgery ensued, and anesthesia pioneers like William McQuiston and Kenneth Keown worked side by side with surgeons during procedures like the first aortic–pulmonary anastomosis and the first transmyocardial mitral commissurotomy. Never before had anesthesia providers worked as intimately with surgeons for the patient’s welfare. The first successful use of Gibbon’s 98 cardiopulmonary bypass machine in humans in May 1953 was a monumental advance in the surgical treatment of complex cardiac pathology that stimulated international interest in open heart surgery and the specialty of cardiac anesthesia. Over the next decade, rapid growth and expanded applications of cardiac surgery, including artificial valves and coronary artery bypass grafting, required many more anesthesiologists acquainted with these specialized techniques. Earl Wynands published one of the first articles on anesthetic management of patients undergoing surgery for coronary artery disease. As cardiac surgery evolved, so did the perioperative monitoring and care of patients undergoing cardiac surgery. Postoperative mechanical ventilation and surgical intensive care units appeared by the late 1960s. Devices like the left atrial pressure monitor and the intra-aortic balloon pump offered new methods of understanding cardiopulmonary physiology and treating postoperative ventricular failure. At Texas Heart Institute, Stephen Slogoff and Arthur Keats demonstrated the negative impact of myocardial ischemia on clinical outcome. By the end of the 1980s, the same duo would reveal that the choice of anesthetic agent had little impact on outcome, challenging the earlier paradigm of “isoflurane steal” proposed by Sebastian Reiz. Developments like cold potassium cardioplegia, monitoring and reversal of heparin, and reduction of blood loss with aprotinin would change the practice of cardiac anesthesia. Transesophageal echocardiography, introduced into cardiac surgery by Roizen, Cahalan, and Kremer in the 1980s, helped to further define the subspecialty of cardiac anesthesia. Neuroanesthesia Brain surgery is considered by some to be the oldest of the practiced medical arts. Prehistoric brain surgery was also practiced by civilizations in South America, Africa, and Asia. Macewen, well known for introducing the technique of orotracheal intubation, promoted the idea of teaching medical students at Glasgow Royal Infirmary the art of chloroform anesthesia. Like Macewen, Sir Victor Horsely was a neurosurgeon with an interest in anesthesia. His experiments of how ether, chloroform, and morphine affected intracranial contents led him to conclude that “the agent of choice was chloroform and that morphine had some value because of its cerebral constriction effects. Meanwhile, Harvard medical student and aspiring neurosurgeon Harvey Cushing developed the first charts to record heart rate, temperature, and respiration during anesthesia. Cushing was one of the first surgeons to recognize the importance of dedicated, specially trained anesthesia personnel versed in neurosurgery. Charles Frazier,121 a neurosurgical contemporary of Cushing, also recognized this need, stating that “no [cranial] operation be undertaken unless the services of a skilled anesthetizer are available. Part of the motivation driving this change was the increased duration in surgical time. Cushing and colleagues used a “slow” surgical technique for most surgical procedures, where the average duration for cranial operations was 5 hours. Therefore, prolonged patient exposure to chloroform or ether anesthesia was likely to result in increased bleeding, postoperative headache, confusion, and/or vomiting. Cushing and his contemporaries thought the use of local or regional anesthesia lessened the risk of these complications. After a decade, it was realized that the remote positioning of the anesthetist was troublesome when managing the airway of an awake or lightly sedated patient undergoing cranial surgery with regional anesthesia. Also, endotracheal tubes, although introduced at the beginning of the century, had become popular instruments for securing a patient’s airway and providing inhalation anesthesia. Combined, these circumstances led to the rapid resurgence of popularity in general anesthesia for cranial surgery, a trend that would continue to the present day. Although the introduction of agents like thiopental, curare, and halothane advanced the practice of anesthesiology in general, the development of methods to measure brain electrical activity, cerebral blood flow, and 100 metabolic rate by Kety and Schmidt and intracranial pressure by Lundburg “put neuroanesthesia practice on a scientific foundation and opened doors to neuroanesthesia research. Many lessons learned during this period of groundbreaking research are still commonly used in modern neuroanesthesia practice. Obstetric Anesthesia Social attitudes about pain associated with childbirth began to change in the 1860s, and women started demanding anesthesia for childbirth. Societal pressures were so great that physicians, although unconvinced of the benefits of analgesia, felt obligated to offer this service to their obstetric patients. This method gained popularity after German obstetricians Carl Gauss and Bernhardt Krönig widely publicized the technique. Numerous advertisements touted the benefits of Twilight Sleep (analgesia, partial pain relief, and amnesia) as compared to ether and chloroform, which resulted in total unconsciousness. Because of the effects of scopolamine, many patients became disoriented and would scream and thrash about during labor and delivery. Gauss believed that he could minimize this reaction by decreasing the sensory input; therefore, he would put patients in a dark room, cover their eyes with gauze, and insert oil- soaked cotton into their ears. The patients were often confined to a padded bed and restrained with leather straps during the delivery. Virginia Apgar’s landmark 1953 publication of a system for evaluating newborns (the Apgar Score) helped to demonstrate that there actually was a difference in the neonates of mothers who had general versus regional anesthesia. Her physicians claimed her death was not related to complications from the method of Twilight Sleep that was used.
Surviving Sepsis Campaign: International Guidelines for management of sepsis and septic shock: 2016 cheap bactrim master card tetracycline antibiotics for acne treatment. Fluid resuscitation in septic shock: a positive fuid balance and elevated central venous pressure are associated with increased mor- tality purchase 960mg bactrim otc antibiotic resistance finder. Fluid resuscitation in septic shock: the effect of increasing fuid balance on mortality buy bactrim 960 mg with mastercard east infection. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. What is the impact of the fuid challenge technique on diagnosis of fuid responsiveness? Comparison of echo- cardiographic indices used to predict fuid responsiveness in ventilated patients. Preload dependence indices to titrate volume expansion during septic shock: a randomized controlled trial. Shock in the frst 24 h of intensive care unit stay: observational study of protocol-based fuid management. Duration of hemo- dynamic effects of crystalloids in patients with circulatory shock after initial resuscitation. Mini-fuid challenge of 100 ml of crystalloid predicts fuid responsiveness in the operating room. Mini-fuid challenge can predict arterial pressure response to volume expansion in spontaneously breathing patients under spinal anaesthesia. Fluid therapy in 2015 and beyond: the mini-fuid challenge and mini-fuid bolus approach. Patterns of intravenous fuid resuscitation use in adult intensive care patients between 2007 and 2014: an international cross-sectional study. A comparison of albumin and saline for fuid resuscitation in the intensive care unit. The role of albumin as a resuscitation fuid for patients with sepsis: a systematic review and meta-analysis. Association between a chloride- liberal vs chloride-restrictive intravenous fuid administration strategy and kidney injury in critically ill adults. Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial. Vasopressors in Sepsis 9 Julian Arias Ortiz and Daniel De Backer Septic shock is the most severe form of sepsis in which profound circulatory, cel- lular, and metabolic abnormalities occur [1, 2]. It is clinically identifed by persis- tent arterial hypotension despite optimal fuid resuscitation requiring vasopressor agents and associated with signs of altered tissue perfusion (altered skin perfu- sion, oliguria, altered mental state) and confrmed by elevated blood lactate levels refecting abnormal oxygen metabolism. The hemodynamic alterations of sep- tic shock are characterized by impaired endothelial function resulting in profound alterations in vascular tone leading to arterial and venular dilation, associated with severe hypotension, hypovolemia (volume loss due to impaired endothelial barrier function and increased permeability and volume redistribution related to dilation of venous reservoir), and impaired blood fow distribution between organs and within organs (microcirculatory level). In most cases myocardial depression has minimal impact on cardiac output and tissue perfusion, but in some cases it may result in an inade- quate cardiac output. Vasopressors are administered to correct hypotension, aiming at restoring tissue perfusion. In this chapter we will review the indications for vasopressor use, the target blood pressure, the hemodynamic and other effects of vasopressors, and the different types of vasopressors. Surgical Intensive Care Unit, Calderon Guardia Hospital, Universidad de Costa Rica, San José, Costa Rica e-mail: julian. Several mechanisms contribute to the decreased vascular tone and include either activation of guanylate cyclase, lead- ing to vasodilation, or impaired sensitivity to vasoconstrictive substances such as catecholamines, vasopressin, and angiotensin (Fig. The decreased sensitivity to catecholamines, vasopressin, and angiotensin is related both to a reduction in the number of the respective receptors and to uncou- pling of the receptor from its intracellular effectors [6–8]. Interestingly, the desen- sitization can vary according to the receptor type, between patients, as well as over time, which may have implications for selection of the vasopressor agents. A patient failing to respond to one agent may respond to an agent from another class. In patients with septic shock, correction of severe hypotension is associated with improvement in creatinine clearance and lactate . Profound and persistent hypotension represents an independent risk of death [12, 13]. Even non-sustained hypotension (<60 min) is associated with poor outcome and should not be neglected . These mecha- nisms adapt the locoregional tissue oxygen transport to metabolic needs. Endothelial dysfunction in sepsis induces changes in blood fow distribution between the different organs. In humans, hepatic fow gener- ally increases in parallel with cardiac output, but hepatic venous saturation (Sho2) can decrease . Autopsy fndings and nuclear magnetic resonance studies suggest ischemic lesions may occur in patients with septic shock . These data suggest that preservation of perfusion pressure is particularly important in sepsis, but that the level of the ideal perfusion pressure for a given individual is diffcult to predict. The generalized endothelial dysfunction of sepsis has been associated with severe microcirculatory alterations in sepsis. On the one hand, vasopressors vasoconstrict precapillary sphincters and venous out- fow, which may impair microvascular perfusion. On the other hand, correction of hypotension may restore the driving pressure of capillaries. Accordingly, the effects of vasopressors on the microcirculation are expected to be highly variable and depend on patient condition. It is impor- tant to consider introduce a vasopressor early in the resuscitation phase of septic shock (salvage phase ), even when hypovolemia has not been completely resolved. Early initiation of vasopressors may be associated with several benefcial effects in septic shock. By restoring vascular tone in capacitance veins, norepinephrine increases cardiac preload. This results in an increase in cardiac output in preload- dependent patients and reduces the degree of preload dependency . This could help to limit the positive fuid balance and prevent harmful fuid overload. Both duration and degree of hypotension have been associated with increased mor- tality in septic shock patients [12, 13] so that it sounds attractive to rapidly correct hypotension. While it is diffcult to conduct randomized trials delaying introduction of vasopressor therapy, observational trials have shown that delay in correcting severe hypotension is associated with an increased mortality rate . Interestingly, these trials failed to show differences in outcome between 65 and 70 mmHg and higher values. Vasopressors cause vasoconstriction, and excessive vasoconstriction can cause two main problems: (1) it can alter the microcirculation and interfere with the mecha- nisms regulating the distribution of blood fow in the periphery, and (2) vasocon- striction can increase afterload and result in impaired right and left ventricular function.
It extends and establishes contact with nephron formation results in arcades or generations of the nephrogenic mesoderm bactrim 480mg overnight delivery xnl antibiotic, also known as the metanephric nephrons arrayed along the medullary rays buy 480mg bactrim free shipping antibiotic resistance youtube. The mature mesenchyme buy bactrim no prescription infection 3 english patch, from which glomeruli and the renal tubules up kidney contains 10–14 nephron generations. The ampullary bud rapidly range contributes to the marked differences in nephron undergoes a series of dichotomous branching. The ﬁrst three number in adults estimated to range from 2,00,000 to to six branches form the renal pelvis and major calyces. From 36 weeks until term, loops of Henle form minor calyces develop from subsequent branches, a process and the proximal and distal tubules elongate and become completed by approximately the 12th week of gestation. This metanephric kidney has now developed to the point at which a collecting system is present. Several centrally located mature glomeruli are present, surrounded by a periph- eral zone of active nephrogenesis. Notice the condens- ing blastemal cells 4 1 Embryology and Normal Kidney Structure 1. The middle and upper Metanephric glomerulogenesis begins during the eighth week portions form the renal tubules. The lower portion forms a of gestation with mesenchymal to epithelial transformation. It is destined to become the podocyte Glomerulogenesis begins with condensation of blastema cells layer of the glomerular tuft. Vascular and mesangial precur- adjacent to the branching ureteric bud to form a cap. Mesangial cell differentiation lular cap condenses into an oval mass that develops a lumen and supporting matrix formation and capillary branching pro- to become the renal vesicle. The one on S-shaped phase; it shows capillary in growth, early podocyte differen- the right illustrates dichotomous branching. A glomerulus on the left induced hollow vesicle formation destined to become a nephron, both shows a small but vascularized glomerular tuft with its proximal tubule the glomerulus and its tubular segments and a ﬂattened parietal epithelial lining Bowman’s space. The third glomerulus to the lower right is fully formed, although the podocytes remain immature, forming a continuous row of cells Fig. The branching ureteric bud on the left has a nephron in the S-shaped phase of development. In this image, the entire sequence of nephro- with a row of immature podocytes below. At the bottom, dichotomous branching ampullary has achieved a spherical shape, with its vascular hilum at the top buds are present. Beneath the blastemal rim, the nephrogenic zone is present with three generations of mature glomeruli below the nephrogenic zone 1. The intervening nephrogenic layers con- tact to form the columns of Bertin shown in the center of this image. Notice that the fetal lobations so This arrangement accounts for the gross lobation of the fetal kidney, as prominent in the newborn kidney (right) have largely disappeared in the shown in Fig. The large difference in renal size principally results from elongation of the tubular portion of the nephron with an increase in tubular cell volume Fig. The prominent fetal lobations, often erroneously adult kidney has deep grooves, representing a ﬂorid example of persis- referred to as lobulations, are apparent on the subcapsular surface. The lobe can be seen on the cut surface to represent an individual corti- lightly granular surface is not normal; it indicates mild injury from comedullary unit in which all cortical nephrons drain into the underly- hypertension and vascular disease ing renal pyramid. Corticomedullary differentiation is evident on the cut surface, with the darker-appearing outer medulla and pale inner medulla, or papilla, easily recognized Fig. The cortex overlays the renal pyramid and extends between the pyramids as columns of Bertin (arrow ). The base of the renal pyramid has faint perpendicular cortical extensions, the medullary rays that contain the same tubular segments present in the outer stripe of the outer medulla (collecting ducts, proximal and distal straight tubules). The pyramids consist of the outer medulla, which has an outer stripe and an inner stripe, and the inner medulla or papilla 6 1 Embryology and Normal Kidney Structure 1. The posterior branch becomes the posterior segmental artery and supplies The fetal kidneys initially are located in the pelvis. Deviation from the rapid caudal growth of the fetus, the kidneys appear to this pattern is common. Segmental arteries branch within the ascend, although they actually gradually relocate to the ret- renal sinus to form several interlobar arteries that enter the roperitoneum, a process that begins in the seventh week of parenchyma between the pyramid surface and a column of gestation and is completed by the ninth week of gestation. The In addition to relocation of the kidneys, their orientation interlobular arteries arise from arcuate arteries and extend changes from an anterior orientation of the hilum to a medial to the renal capsule, supplying ﬁve to six glomeruli with an orientation of the hilum. The glomerular efferent (exiting) arteriole The adult kidney averages 11–12 cm in length, 5–7 cm in gives rise to the peritubular capillaries. Its weight ranges from 125 illaries comprise a lush and complex labyrinth that tightly to 170 g in men and 115–155 g in women. Cortical by a ﬁbrous capsule and have a concave medial surface, the venules empty into the interlobular veins. They descend and hilum, through which the arteries enter and the ureter, veins, converge to form arcuate veins that have abundant anasto- and lymphatics exit. The subcapsular surface of the kidney moses and lateral tributaries that encircle the renal pyramids may be smooth and featureless or show the outlines of renal and calyces. Arcuate veins join to become interlobar veins in lobes, known as persistent fetal lobation, an anatomic variant the renal sinus. The collecting system consists and the spiral arterial branches of interlobar arteries branch to of 9–11 funnel-shaped minor calyces that surround the indi- form capillaries that nourish the inner medulla, also known as vidual papillary tips. Minor calyces unite to form major calyces, eruli descend toward the medulla and converge as the descend- which then merge to form the renal pelvis. There is no dis- ing arteriolar rectae, forming organized bundles in the inner tinct delineation between the pelvis and the ureter; rather, a stripe of the outer medulla. The ascending arte- The main renal artery divides into anterior and posterior riolar rectae form the venous return, which generally follows branches. The anterior branch gives rise to four segmental the descending arteriolar rectae and empties into the arcuate arteries that supply the anterior middle portion and both veins. Notice that the right renal artery is slightly longer than the left, whereas the left renal vein is lon- ger than the right. The left adrenal vein (arrow) arises from the left renal vein and can be seen angled upward, whereas on the right side the adre- nal vein (not shown) arises from the vena cava Fig. Three medullary rays (arrows) are shown here with their linear array of tubules that descend to, and ascend from, the renal medulla. The cortical labyrinth between the medullary rays contains glomeruli, proximal and distal convoluted tubules, connecting tubules, and the initial portion of the collecting ducts, as well as interlobular arteries and veins, arterioles, venules, capillaries, and lymphatics Fig. The main renal artery (top hemostat) usually divides into anterior and posterior branches that give rise to ﬁve seg- mental arteries proximal to the renal hilum. Similarly, the main renal vein (lower hemostat) often forms outside the kidney as two or more tributary veins converge as they exit the kidney. The arteries and veins interdigitate, and both vas- cular groups lie anterior to the renal pelvis and ureter Fig. The longitudinally oriented tubules within the medullary ray on the left contain the descending proximal straight tubules and collecting ducts, and ascending distal straight tubules.
Te controller displays device main parameters humanitarian exemption from 2005 in children such as pump fow (L/min) buy bactrim 960 mg without a prescription virus joke, power consumption 5–16 years of age with end-stage heart failure (watts) bactrim 480mg with mastercard dosage of antibiotics for sinus infection, pump speed (rpm) purchase bactrim with visa antibiotic ointment for stye, and battery charge. A pump holder ring is sewed with 8–12 U Anticoagulation management for patients with pledgeted stitches on the lef ventricular apex. Te surgeon must pay are coated with Carmeda® BioActive and prelimi- attention during this procedure to ensure a full- nary data report encouraging result on preventions thickness incision and detaching of the muscle in of thromboembolic events; however, new data the apex to allow a perfect ft of the infow cannula on this issue are still needed. Together with the anticoagula- Te infow cannula is then secured by sewing the tion therapy should be introduced an antiplatelet infow cannula ring to the previous apical fxation therapy; this has been proved to reduce risk of ring. Panel a, handle temporary fxation of apical sewing cal view ring and fast connect device. Nevertheless, in adult patients, the lef thoracotomy (4th–5th intercostal space) allows the surgeon to a better view of the lef apex, and the outfow graf can be anastomosed to the descend- ing aorta. A lef mini-thoracotomy (4th–5th intercostal space) may be performed for lef ventricle apex exposure. Te outfow cannula anastomosis is instead per- formed through a right mini-thoracotomy or a J-shaped upper mini-sternotomy. Additionally, this ofers the chance to remove the cable in case of driveline wound infection with- be performed also on beating heart. However, adverse from the probe to the controller and the other events such as infections, thromboembolic com- transferring power from the controller to the plications, and technical failures limited their use pump motor. Te recently introduced With the HeartAssist Remote™ Monitoring axial-fow devices (e. Tey also their heart health while enjoying life at home or show lower rate of both related complications and traveling. Goldstein  and colleagues helping to avoid unnecessary hospital admis- have reviewed 150 patients worldwide under- sions. From their review, 55% were either bridged lead to an efective deployment resulting in to transplantation or recovery or are ongoing, better use of the healthcare system’s resources. Patients with these devices could achieve a good theoretical, and, despite all potential clinical ben- quality of life afer discharge from the hospital. Te common elements are energy trans- and may decrease the number of unnecessary fer coils, sealed internal battery, tiny and efcient ambulatory visits, still a question remains unre- motor controller, power draw of just 5. Ann Chairman of the Board of Directors of ReliantHeart Thorac Surg 71:S133–S138 ; discussion S144-136 Inc. Timms D (2011) A review of clinical ventricular assist B, Kemper D et al (2001) Clinical experience with nine devices. J Thromb Thrombolysis thrombogenicity emulation- optimized heartassist 5 39:337–344 vad. Agati S, Bruschi G, Russo C, Colombo T, Lanfranconi M, 54 Bohm M, Dickstein K et al (2012) Esc guidelines for the Vitali E (2001) First successful italian clinical experi- diagnosis and treatment of acute and chronic heart ence with debakey vad. J Heart Lung Transplant failure 2012: the task force for the diagnosis and treat- 20:914–917 ment of acute and chronic heart failure 2012 of the 25. Developed in collab- replacement of malfunctioning tci heartmate lvad oration with the heart failure association (hfa) of the with debakey lvad as a bridge to heart transplanta- esc. Tese rotary fow devices contain narrow gaps and mechanical or hydrodynamic bearings and produce continuous fow in a high-shear environment. Right sis, acquired von Willebrand factor defciency, and ventricle with membrane, 2. Te blood-contacting layer of this resulting in complications related to right-sided membrane consists of bovine pericardial tissue 55 congestion, such as renal failure and right heart chemically treated with glutaraldehyde. It uses external fexible polyurethane bag that serves as a reservoir air compressors to activate the pumps, constrain- and compliance chamber for the actuating liquid. It is intended to results in a harmonious deployment of the hybrid provide biventricular replacement therapy for membranes, with flling and emptying of the blood patients with advanced heart failure. Te auxiliary pump shuttles the actuating liquid between the lef ven- tricle and the compliance chamber. An accelerometer located on the elec- pressure, but can operate within a pressure range tronic board provides information about position from −10 to +250 mmHg on the lef and right side. Ultrasound trans- the electronics that drive the pumps embedded ducers in each ventricle measure the position of inside the device. Tey register ventricular pres- and transducers is analyzed and processed by sures throughout the pumping cycle, providing a microprocessor on the electronic board. Tis instant information about flling and ejecting microprocessor communicates with another mic- pressures. A third pressure sensor is located in roprocessor that executes sofware whose algo- the compliance chamber of the fexible polyure- rithms control the activity of the motor pumps. Tis sen- Intraventricular pressure curves are displayed sor provides information about pressure in the real time on the hospital care console monitor pericardial space and may be helpful in clinical (. Te driveline exits the skin at the were tested in mock circulations and on dura- lower lef of the abdomen, where it is connected bility bench tests. From the 2D scans, a three-dimensional 5 No contact between blood and pumps (3D) model of the thorax and its structures is 5 Gradual deployment of stroke volume with created. Te infow areas of the 55 5 Pulsatile fow 3D model are placed at the right and lef atrio- 5 Self-containing system with on-board ventricular junctions and the outfow areas at electronics and microprocessors the pulmonary artery and aorta. Based on these 5 Automatic response with variation in pump placements and the resulting position of the 3D fow, according to the patient’s needs model relative to the chest wall and diaphragm, 5 Biventricular support the implanting surgeon determines whether the 5 Completely incorporated in the pericardial sac device fts (. The Te bioprosthetic surfaces of the device, the pump rate can be manually increased but high atrial suture fanges, and the biological valves are pressure on the suture lines should be avoided. During the initial When deairing is completed (eventually con- phase of the surgical procedure, these surfaces are firmed by echo), the aorta clamp is removed. Te pericardial space is accessed through pressure, the clinician can set the pump rate, a median sternotomy and a midline vertical inci- the left ventricular stroke volume, and the ratio sion of the pericardial sac. Afer cross clamping, the native ventricles Meticulous hemostasis is performed; the peri- are excised up to the lef and right atrioventricular cardium and sternum are closed, leaving drains junctions. Te diameter of the atrioventricular orifces is measured with sizing tools (30-35-40-45 mm). Te tings can be switched from manual mode to silicone ring of each fange is connected to a single automatic response mode. Te membrane deployment in 30 mm diameter) with outfow valve is sutured to diastolic phase is controlled to achieve the pre- the distal pulmonary artery. Both arterial suture set flling pressure and maximizes stroke vol- lines are lef open to facilitate deairing. In case of low systemic arterial pressure Deairing cannulas are inserted through the (e. Left panel: showing device parameters that can (turquoise line) be adjusted by the clinician. An educational program 55 in the automatic mode to prevent the prosthesis is initiated to prepare the patient and his personal from increasing its blood fow in case of sudden caregiver in managing the external equipment.