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This technique is very useful for aneurysms ing that was later conﬁrmed in clinical studies  buy cyklokapron 500mg without a prescription symptoms 2016 flu. While Bigelow was performing his surface cooling For aneurysms that extend into the arch from the aortic experiments in Toronto cheap cyklokapron treatment zinc poisoning, Ite Boerema and colleagues in root and involve annuloaortic ectasia buy genuine cyklokapron on-line medications voltaren, Bentall developed a Amsterdam were experimenting with central cooling and procedure for replacing the entire diseased segment and re-warming , in which blood was removed from an aortic valve with a fabric graf containing a mechanical artery, cooled or warmed by an external device, and then prosthetic valve . This work led to the development of care for 25 years, but like all mechanical valve implan- of cooling methods that could induce deep hypothermia tations, it required the patient to take anticoagulant medi- (i. Therefore, in the of deep hypothermia and circulatory arrest with open early 1990s, Yacoub  and David  each devised anastomosis was ﬁrst used to treat extensive aortic arch alternative procedures in which the native valve could aneurysms by Christiaan Barnard in 1963 . It was sub- be spared by reshaping the aortic annulus (Yacoub) or by sequently used by Dumanian  to repair a traumatic mobilizing the native valve and reimplanting it inside the aneurysm of the transverse arch in 1970, and for prosthetic synthetic graf (David). Deep hypothermia and circulatory arrest provided considerable protection of the central nervous Combined surgical and endovascular system during the procedure, but the technique was not approaches without disadvantages; it was time-consuming, and it could cause coagulopathy, which increased the patient’s Simultaneous with the reﬁnement of surgical approaches risk of intra-operative bleeding and post-operative stroke to aortic arch repair has been the rise of modern endovas- and death . Although endovascular stent-grafing has colleagues recommended initiating moderate systemic been used successfully in the abdominal aorta and, more hypothermia and shortened periods of total circulatory recently, in the descending thoracic aorta, strictly endovas- arrest afer the aortic arch vessels were clamped . The curve of the arch have produced good short-term results, but litle is yet complicates stent deployment in some cases, and, more known about their long-term outcomes. This occlusion may be tolerable in the lef subclavian artery [70,71] (unless the Conclusions aneurysm involves this artery) but not in the lef common carotid or innominate arteries. Human beings have been aware of aneurysms for mil- For these reasons, hybrid procedures have begun to lennia, but only in the past century has surgical repair of be developed for aortic arch repair. These are generally the aortic arch progressed from being impossible to being 2-stage procedures in which open surgery is performed a desperate last resort to becoming a viable treatment ﬁrst to create landing zones for the graf , to transpose option. These procedures merely to remove the aneurysm but to restore circulation to all vital tributaries. Further improvements in surgical adjuncts and in hybrid surgical/endovascular techniques will make this goal achievable in an ever larger propor- tion of patients than is possible today. On the treatment of aneurism by elec- aortic aneurysm with restoration of vascular continuity using a fabric graft. Greenwich Medical Media, London, Successful resection of fusiform aneurysm of aortic arch 2001: 73−78. Intervention chirurgicale directe pour un aneu- Henry Ford Hospital International Symposium on Cardiac rysme de la crosse de l’aorte, ligature du sac. Med from vinyon N cloth in bridging arterial defects: experimen- News 1888; 53: 462−466. Surgical considerations of intra- of preparing woven Dacron aortic grafts to prevent intersti- thoracic aneurysms of the aorta and great vessels. Definitive treatment of saccular aneurysms of mosis: improved results in the treatment of aneurysms of the the aorta with excision of sac and aortic suture. The surgical vision closure of ventricular septal defects in eight patients treatment and the physiopathology of coarctation of the by means of controlled cross circulation. Application of a mechanical heart and lung studies regarding its surgical correction. Thoracic and clinical appraisal of coarctation four to seven years after Cardiovascular Surgery, 4th edn. Preliminary obser- aorta and aortic arch using circulatory arrest and retro- vation on the use of human arterial grafts in the treatment grade perfusion] Nippon Kyobu Geka Gakkai Zasshi 1988; of certain cardiovascular defects. Ann Thorac shunts to permit occlusion, resection, and frozen homologus Surg 1986; 42: 273−281. Total excision of trophrenic respirations, an artificial pacemaker for cardiac the aortic arch for aneurysm. Surg Gynecol Obstet 1955; 101: standstill and radio-frequency rewarming in general hypo- 667−672. Ann Thorac Surg 2005; aid of hypothermia: experimental accomplishments and the 80: 2166−2172. Ann Thorac Surg 2002; 74: plications after cardiopulmonary bypass: cerebral protection 1803S−1805. J Thorac Cardiovasc Surg 1992; 103: hypothermia and circulatory arrest in the surgical treat- 617−621. Resection of the aortic arch Intentional left subclavian artery occlusion by thoracic aortic using deep hypothermia and temporary circulatory arrest. Combined approach in acute aortic dissection: preliminary clinical results with to stent-graft treatment of an aortic arch aneurysm. Extensive aortic replace- for distal aortic arch aneurysm: combined cervical branch ment using “elephant trunk” prosthesis. Elephant trunk technique in complex aortic pathology: the “bidirectional” procedure: newer indications and uses. Surgical Treatment of elephant trunk technique used for treatment of complex Aortic Aneurysms. Accordingly, the anatomy of the aortic arch and neighboring structures has become of The anatomy of the aortic arch is treated sparsely in most increasing practical importance to the practicing cardio- anatomy texts. The application of the technique of profound hypother- mia and circulatory arrest in the management of aortic Normal anatomy arch disease was pioneered by Griepp and associates in the mid-1970s. Research expanding our understand- The limits of the aortic arch are deﬁned anatomically ing of neuroprotection over the ensuing decades and by the origins of the brachiocephalic vessels. By convention, reﬁnements in surgical techniques and technologies  the arch begins just proximal to the origin of the innomi- have opened the door for the surgical correction of an nate artery and ends just beyond the lef subclavian artery. Aneurysms The arch itself is classically divided into proximal and (a) (b) Right common carotid artery Left common carotid artery Right subclavian artery Left subclavian artery Innominate 1 2 artery Distal 0 3 segment Proximal segment Isthmus Tubular portion Ligamentum arteriosum Transverse arch Ascending aorta Descending aorta 4 Aortic root Figure 2. Zone 0 is proximal to the origin of the innominate artery; zone 1 is between the origins of the innominate and left common carotid arteries; zone 2 is between the origins of the left common carotid and left subclavian arteries; zone 3 is within 2 cm distal to the origin of the left subclavian artery; and zone 4 is beyond 2 cm distal to the origin of the left subclavian artery. This relationship is of particularly impor- With the recent advent of endovascular stent-grafing tance when conducting a vascular anastomosis at the level and a need to deﬁne ‘landing zones’ precisely, an alterna- of the subclavian artery. Deep sutures here can violate tive map of the aortic arch has been proposed as shown the esophagus with predictably disastrous results. This classiﬁcation scheme is now widely airway itself is seldom visualized during arch surgery, as used by endovascular surgeons . The diameter of the entire aorta increases how much of the arch can be visualized from the medias- with normal aging, however. The isthmus, deﬁned as the tinal approach simply by dividing the pericardial reﬂec- region of the distal arch lying just between the origin of the tion on the aorta and bluntly dissecting a few centimeters subclavian artery and the ductus arteriosus (or ligamen- distally. The origins of all three brachiocephalic vessels tum arteriosum in the adult) may have a mild narrowing are readily apparent with this simple maneuver. The most common variant is the so- Great vessels configurations called bovine arch in which the lef carotid artery originates from the innominate artery (Figure 2. Less common, but of particular importance in the era of endovascular stent-grafing, is where there is a separate origin of the lef vertebral artery from the arch between the lef carotid and lef subclavian arteries. This anomaly is not rare, and particular atention must be paid to the direction of ﬂow in both vertebrals as well as the patency of the circle of Willis should occlusion of the lef vertebral be Normal 5% 11% 0. This arrangement is ofen associ- frequency with which these patterns are observed is broad.
Chronic persistent myocarditis (7% of myocarditis cases) has an indistinct onset discount 500mg cyklokapron visa medicine in ancient egypt, with nonresolving active or borderline inflammatory infiltrates seen on histologic examination order discount cyklokapron on line symptoms xanax treats. Histologic classification of myocarditis order cyklokapron visa treatment modalities, also called the Dallas classification (1986) 1. Myocarditis: myocardial necrosis or degeneration, or both, in the absence of significant coronary artery disease with adjacent inflammatory infiltrates or fibrosis, or both b. Borderline myocarditis: inflammatory infiltrates too sparse or myocyte damage not apparent c. A minimum of 14 infiltrating leukocytes per mm (1), preferably T lymphocytes, and up to four macrophages may be included. Myocarditis can be totally asymptomatic or can manifest with chest pain syndromes ranging from mild persistent chest pain of acute myopericarditis (35% of cases) to severe symptoms that mimic acute myocardial infarction. Chest pain associated with coronary artery vasospasm may rarely occur in patients with myocarditis. Alternatively, chest pain may be more typical for pericarditis, suggesting pericardial involvement. About 60% of patients may have antecedent arthralgias, malaise, fever, sweats, or chills consistent with viral infections (e. In many patients who develop heart failure, fatigue and decreased exercise capacity are the initial manifestations. However, diffuse, severe myocarditis can progress rapidly and result in acute myocardial failure and cardiogenic shock. The diagnosis is usually presumptive, based on patient demographics and the clinical course (i. In some instances, patients may present with arrhythmia in the form of syncope, palpitations caused by heart block (i. Sinus tachycardia is more frequent than serious atrial or ventricular arrhythmias. Palpitations secondary to premature atrial or ventricular extrasystoles are common. Patients often present with signs of acute decompensated heart failure, including an S3 (third heart sound) gallop, central and peripheral edema, jugular venous distention, and tachycardia (see Chapter 8). Sarcoid myocarditis: lymphadenopathy, also with arrhythmias, and sarcoid involvement in other organs (up to 70%) 2. Acute rheumatic fever (usually affects the heart in 50% to 90%): associated signs such as erythema marginatum, polyarthralgia, chorea, and subcutaneous nodules (i. Hypersensitive or eosinophilic myocarditis: pruritic maculopapular rash and history of onset temporally related to initiation of potential culprit medications 4. Leukocytosis is common (often lymphocytic), although the presence of eosinophilia may suggest hypersensitive (eosinophilic) myocarditis. Elevated acute phase reactants such as erythrocyte sedimentation rates or ultrasensitive C- reactive protein are good monitors of clinical progression or response to therapy, but they have low specificity for myocarditis. Novel inflammatory markers under investigation include tumor necrosis factor-α, interleukins, interferon-γ, serum-soluble Fas, and soluble Fas ligand levels. Serum viral antibody titers are usually increased fourfold or more acutely and gradually fall during convalescence. Disease-specific testing is indicated if the following conditions are suspected: 1. Serum cardiac enzymes (markers of myonecrosis): creatinine kinase (myoglobin subfraction) is elevated in only 7. Pericarditis can accompany myocarditis and is often manifested in pericarditis like changes seen on electrocardiography. In some cases, fascicular block or atrioventricular conduction disturbances and ventricular tachyarrhythmia may be hemodynamically significant. Occasionally, focal wall motion abnormalities and presence of pericardial fluid may prompt further workup or intervention. Fulminant myocarditis is often characterized by near-normal diastolic dimensions and increased septal wall thickness, whereas acute myocarditis often has increased diastolic dimensions but normal septal wall thickness. In a series of 23 patients with biopsy-proven myocarditis, significant reduction in right ventricular function was a powerful predictor of death or the need for cardiac transplantation. Gallium scanning identifies severe myocardial cellular infiltration with high specificity (98%) but low sensitivity (36%). Cardiac angiography is often indicated to rule out coronary artery disease as the cause of new-onset heart failure, because the clinical presentation of myocarditis may mimic myocardial infarction (i. Cardiotropic viruses such as enteroviruses (specifically, the coxsackie group B and echoviruses) may cause direct cardiotoxic injuries, cytokine activation, cytoskeletal damage, and autoimmune responses. However, data suggest that the incidence of myocarditis after infection is lower than previously projected. Viral myocarditis is often considered when accompanied by a clinical picture of recent febrile illness, often with prominent myalgias, followed by rapid onset of cardiac symptoms. However, direct proof is lacking (and often unnecessary), and many cases of idiopathic dilated cardiomyopathies have been attributed to antecedent viral myocarditis. Cardiomyopathy caused by Trypanosoma cruzi in South and Central America, particularly in persons aged 30 to 50 years. Cardiac involvement usually appears decades after initial treatment and is the leading cause of death of persons aged 30 to 50 years in the endemic areas. Occasionally hepatosplenomegaly and lymphadenopathy occur, but concomitant meningoencephalitis is rare. These manifestations often result from pathogen-induced cytotoxicity and inflammatory responses. Approximately 5% to 10% of affected patients may develop direct acute-to-chronic progression. The hallmark feature is the presence of fused, multinucleated (>20 nuclei) epithelioid giant cells of histocytic origin within a diffuse, intramyocardial inflammatory infiltrate with lymphocytes. Rapidly progressive heart failure is the presentation in 75% of affected patients. The prognosis is dismal without therapy, but the disease is often refractory to standard medical therapy, with a 1-year mortality rate of up to 80% (median survival of 3 to 5 months from symptom onset). Small observational series have suggested potential benefits of immunosuppressive therapy, and a randomized, prospective multicenter study is ongoing. Consideration for early cardiac transplantation is appropriate (71% 5-year survival after successful transplantation). Often, mechanical support may be required as a temporary bridge to recovery or transplantation. Drug-induced eosinophilic myocarditis is independent of cumulative dose and duration of therapy. The absence of peripheral eosinophilia does not rule out eosinophilic myocarditis. Although observational series suggest potential clinical benefits of corticosteroid therapy, the best strategy is to remove the causative agent when known. Collagen vascular diseases such as Wegener granulomatosis or Churg–Strauss syndrome (i.
A thorough differential diagnosis of nonmalignant conditions must be considered and ruled out cyklokapron 500 mg discount symptoms at 6 weeks pregnant. Possibilities include pericardial cysts purchase cyklokapron 500mg amex medicine lake montana, teratomas order cyklokapron 500mg on line treatment 6th nerve palsy, lipomatous hypertrophy of the interatrial septum, thrombus, and sarcoid. Unfortunately, the final diagnosis in many cases must still be made pathologically. The primary therapy for benign tumors remains operative resection, given the associated risk of lethal obstruction, arrhythmia, or embolization. Most surgeons perform excision with extracorporeal circulatory support in order to directly visualize the tumor, as well as a careful search for metasynchronous tumors. The femoral or azygous vein is usually cannulated, as opposed to the right atrium, to avoid potential tumor fragment embolization. Mitral valve repair or replacement is usually unnecessary in the absence of associated bacterial endocarditis. An analysis reviewing 106 operations for sporadic atrial myxomas noted only one perioperative death. Survival at 25 years is no different when compared with age- and sex-matched controls. There are limited data regarding the use of a minimally invasive or robotic approach to cardiac tumor resection. Small series suggest that parasternal or partial sternotomy access does not compromise the safety or efficacy while allowing for shortened hospitalization and better cosmetic results. Regardless of the type of surgical resection or whether the tumor is sporadic, annual follow-up noninvasive imaging is recommended in all patients after resection. Recurrence rates of 12% to 22% have been quoted in patients with family histories, syndromes, and multiple tumors at original presentation versus 1% for patients with sporadic, isolated myxomas. They are rarely cured by surgery because of the large amount of cardiac tissue involved. Cardiac transplantation has been performed for patients with both benign and malignant tumors, but thus far, series have been too small to reliably predict outcomes. Patel, Adam Grasso, and Nitin Barman for their contribution to earlier editions of this chapter. Carney complex: the complex of myxomas, spotty pigmentation, endocrine overactivity and schwannomas. Primary cardiac tumors: early and late results of surgical treatment in 91 patients. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. There appear to be gender- based differences in the atherosclerotic process of men versus women. Women, in general, have more diffuse atherosclerosis with less plaque volume and luminal obstruction than males. The underlying mechanism of thrombosis also appears to differ, with thrombosis in women resulting from superficial erosion of intact atheroma versus frank plaque rupture in males. Vasoreactivity, thrombosis, and inflammation are influenced by a variety of hormones, present in varying quantities in men and women. Women have smaller coronary arteries than men and, interestingly, women taking androgens have much larger coronary arteries than their age-matched controls. There is no known treatment or risk factor modification for microvascular dysfunction. Diagnosis is a process of exclusion, including angiography which often reveals normal coronary vessels. The etiology of stress cardiomyopathy is not fully elucidated, but is believed to result from catecholamine toxicity with excessive sympathetic stimulation of the basal segment of the heart. Microvascular dysfunction and/or coronary vasospasm may also contribute to the pathophysiology of stress-induced cardiomyopathy. The prognosis of stress cardiomyopathy is very good, with the majority of patients recovering full ventricular function within weeks to months. Smoking also has an antiestrogen effect, inducing unfavorable changes in lipid levels. However, with smoking cessation, risk is cut in half after 1 year without smoking and eventually declines back to baseline nonsmoker’s risk. The predominant source of estrogen changes from estradiol in the premenopausal state to the much weaker hormone estrone (produced by the conversion of androgens in peripheral adipose tissue) during menopause. For this and other reasons, research has been focused on identifying other novel biomarkers that can better define a woman’s risk. Each biomarker tended to identify different high-risk groups, but better prognostic values were obtained when both were used together. Like men, women can present with typical symptoms of angina, such as substernal chest pain and dyspnea on exertion that is relieved by rest. These symptoms more often occur in older women, who present more similarly to men. Women can also present with atypical chest pain; shortness of breath; neck, shoulder, or arm pain; diaphoresis; and nausea/vomiting. Women are more likely to have subtle symptoms that require detailed history- taking to elicit, such as chest “pressure or tightness,” lightheadedness, palpitations, or fatigue. Women most often have symptoms that occur at rest, wake them from sleep, or occur in times of psychological stress. Women more often present acutely without preexisting prodromes of symptoms or with sudden cardiac death. In general, women are more likely than men to have a false positive stress test; however, a negative exercise stress test has a negative predictive value of ~80%. For those individuals unable to exercise or attain target heart rates, adenosine or dipyridamole can be used as a pharmacologic stress agent. To increase specificity, the higher energy isotopes (technetium 99m) are recommended in women to reduce the soft tissue attenuation artifacts (influenced by both breast tissue and obesity) that tend to occur anteriorly and laterally. The occurrence of a complication is thought to be related to older age at the time of presentation, smaller body size, smaller vessel size, and higher prevalence of diabetes. A radial approach to diagnostic and interventional coronary procedures leads to less bleeding complications than femoral catheterizations in both men and women and, when feasible, should be considered in women. Until recently, most of the clinical trial data, on which the guidelines for prevention and treatment of both genders are based, were derived from trials conducted largely in men. This information had been extrapolated to women because gender-specific trial data were lacking. Because of this uncertainty, more recent clinical trials have offered insights into gender-specific results, allowing for evidence-based guidelines for disease prevention and treatment in women. However, with only a few exceptions, the guidelines are the same for both men and women. The gender-specific results are highlighted here; for a full discussion, please see appropriate sections of previous chapters. However, there are very few gender-specific data in these instances, so most recommendations are extrapolated from trials conducted largely in men.