Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2007
ReviewMinimally invasive surgery with a partial sternotomy "J" approach.
The minimally invasive partial sternotomy "J" incision can be used for most isolated mitral valves, tricuspid valves, aortic valves, atrial septal defects, maze procedures, aortic repairs, and aortic valve reoperations. This article reviews the technical approaches and outcomes for various procedures. ⋯ Similar results have been obtained for aortic valve procedures. Thus, all patients undergoing isolated aortic or mitral valve repairs are offered a minimally invasive operation.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2007
ReviewCause and prevention of central nervous system injury in neonates undergoing cardiac surgery.
Neurologic morbidity has been identified as increasingly problematic in neonates with congenital heart disease as surgical mortality rates have improved. The presence of "congenital brain disease" in patients with congenital heart disease represents a challenge in improving long-term neurologic outcomes. Mechanisms of central nervous system injury in infants undergoing cardiac surgery include hypoxia-ischemia, emboli, reactive oxygen species, and inflammatory microvasculopathy. ⋯ Postoperatively, secondary neurologic injury may be related to post-cardiopulmonary bypass alterations in cerebral autoregulation and additional hypoxic-ischemic insult, seizures, or other issues associated with prolonged intensive care unit stay. In addition to prenatal and modifiable perioperative factors, genetic and environmental factors are known to be important. Unfortunately, modifiable perioperative factors may explain less of the variability in long-term outcomes than do patient-specific factors.
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Since its first description, acute respiratory distress syndrome has been characterized by abnormal physiologic and gas exchange properties of the lungs. Many adjunctive therapies have been developed to reduce the stresses of mechanical ventilation on already damaged lungs. We examined the mechanism of action and the latest clinical trial information of several adjunctive therapies including prone positioning, nitric oxide, extracorporeal membrane oxygenation, arterial venous carbon dioxide removal, and liquid ventilation. While all of these therapies have demonstrated short-term improvements in arterial blood gases and in the limitation of lung injury, none have shown an evidence-based survival benefit.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewARDS and diffuse alveolar damage: a pathologist's perspective.
Diffuse alveolar damage (DAD) is the histologic correlate of most patients with adult respiratory distress syndrome (ARDS). It is a relatively straight forward diagnosis and the main differential diagnosis clinically is acute pneumonia and histologically is bronchiolitis obliterans and organizing pneumonia (BOOP). The histologic progression of DAD includes 3 phases (exudative, proliferative, and fibrotic) that correlate with the time rather than its specific cause. The factors that govern which patients will do well and which will develop a fulminant course is not known.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewIntraoperative management of hyperglycemia in the cardiac surgical patient.
The stress response of cardiac surgery leads to hyperglycemia, and undergoing cardiopulmonary bypass magnifies this response greatly. Counter-regulatory hormones, the cytokine response, and the automatic nervous system are all part of the coordinated host response that can lead to hyperglycemia. Postoperative hyperglycemia is associated with worsened perioperative outcomes, and there are data demonstrating this to also be true for the intraoperative period. ⋯ Intraoperative glucose control has a significant impact on postoperative outcomes. No optimal intraoperative insulin regimen has been identified, but continuous intravenous infusions appear to be superior to intermittent sliding scale dosing. In addition, the technique of hyperinsulinemic glucose clamp shows the greatest promise of achieving normoglycemia while on CPB.