Cardiology clinics
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The purpose of this chapter is to provide a brief overview of the current place of open surgical repair for abdominal aortic aneurysms with respect to the factors influencing clinical decision-making, the operative techniques most frequently used, and some of the complications commonly encountered in the postoperative period.
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Pulmonary arterial hypertension (PAH) is a recognized complication of congenital systemic to pulmonary arterial cardiac shunts. The prognosis of PAH in this situation is better than primary or other secondary forms of PAH. Our knowledge of the pathophysiology of PAH complicating congenital heart disease has evolved over the past decade. Despite differences in etiology and pathobiology, therapies that have proven successful for primary PAH may benefit this group of patients.
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The role of surgery and radiofrequency current ablation for the treatment of tachycardias in patients with congenital heart disease The use of radiofrequency current application as a treatment strategy has stimulated a revolution in our understanding of tachycardia mechanisms. The extension of its use to patients with congenital heart defects and tachyarrhythmias has opened the door to new treatments with known success rates and known risks for mortality and morbidity. Antiarrhythmic surgery aims to dissect or excavate a responsible substrate and is especially worth considering if cardiac surgery is being undertaken for other reasons. ⋯ Despite the immense growth of knowledge and experience in recent years, there is still a need for more knowledge about the factors causing arrhythmogenesis and their interactions. Prospective and randomized studies are needed to show the most effective strategies to prevent arrhythmia-mediated death. The future of antiarrhythmic treatment will less be directed by the limitations of current interventional tools, which will be improved, and more by an evolutionary process in philosophy regarding the understanding of arrhythmogenesis in these patients as the basis for new concepts of arrhythmia prevention and treatment.
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The importance of vital organ perfusion in patients suffering cardiac arrest makes arterial vasomotor tone, and the resultant perfusion pressure, critical in resuscitation from sudden death. Although there are multiple mechanisms that may affect arterial vascular tone, historically, the therapy most commonly used has been catecholamine-induced adrenergic receptor stimulation, with catecholamine epinephrine being the commonest drug used. Over the last decade, however, it has become widely known that the utility of epinephrine during cardiopulmonary resuscitation is undefined. ⋯ Other agents appear promising. This article addresses pressor drugs and adrenergic agonists, including a review of their history, basic science, mechanism of action, and efficacy. Epinephrine is reviewed.
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CPR represents the primary intervention used during cardiac arrest for maintaining perfusion and extending the potential resuscitation period. Effective CPR, however, requires careful attention to detail by the resuscitation team, including (1) effective control of the airway using manual maneuvers or airway adjuncts, (2) delivery of effective ventilation that assures adequate oxygenation, while reducing the chance for gastric inflation, and (3) chest compressions delivered at the appropriate depth and rate using a duty cycle of 50% compression and 50% release. During the resuscitation effort team leaders should closely monitor the performance of CPR, rotate rescuers frequently to avoid fatigue, and provide continuous feedback based upon direct (transmitted pulse, chest rise) and indirect (end-tidal CO2) measures of effectiveness. A careful and measured approach to CPR performance, combined with a strong chain of survival, provides victims of cardiac arrest the best chance for survival.