The document discusses the venous anatomy of the heart, including the coronary sinus and persistent left superior vena cava (LSVC). It begins with the embryological development of the venous system. It then describes the various tributaries that drain into the coronary sinus and provides an overview of the venous drainage patterns. It discusses surgical implications of anomalies such as LSVC connection variations, coronary sinus atresia, and partial unroofing of the coronary sinus.
The conotruncus comprises collectively two myocardial subsegments, the conus and the truncus.
Conus is the myocardial segment between ventricle and semi lunar valves which gives rise to sub arterial coni.
Truncus is the fibrous segment between semi lunar valves and aortic sac which gives rise to great arteries.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
The conotruncus comprises collectively two myocardial subsegments, the conus and the truncus.
Conus is the myocardial segment between ventricle and semi lunar valves which gives rise to sub arterial coni.
Truncus is the fibrous segment between semi lunar valves and aortic sac which gives rise to great arteries.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
TAPVC defines the anomaly in which the pulmonary veins have no connection with the left atrium. Rather, the pulmonary veins connect directly to one of the systemic veins (TAPVC) or drain in to right atrium.
A PFO or ASD is present essentially in those who survive after birth
When pulmonary veins drain anomalously into the right atrium either because of complete absence of the interatrial septum or malattachment of the septum primum , then it is known as total anomalous pulmonary venous drainage.
When some or all of the pulmonary veins drain anomalously in to RA or its tributaries without being abnormally connected, the terms partially anomalous pulmonary venous drainage (PAPVD) or totally anomalous pulmonary venous drainage (TAPVD) with normal pulmonary venous connections are used.
Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms, and the later symptoms are usually nonspecific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced.
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a cardiac surgery presentation about Atrioventricular septal defect,Definition, Prevalence,Anatomy,Classification,presentation ,diagnosis and management
Generally occurs secondary to pulmonary atresia with intact IVS .
Pathophysiology- it develops because of a reduction in the blood flow secondary to inflow impedence from tricuspid atresia or outflow impedence from pulmonary arterial atresia .
Typical findings- a small , hypertrophic RV and a small or absent pulmonary artery
What separates an accomplished cardiac surgeon from the reat is the right patient selection for surgery. This PPT will give insight when its best not to opearte on a mitral valve
This presentation is no way to discredit TAVI or bring the positives of SAVR. Its about trials when short term outcomes of TAVI are compared to long term benefits of surgery.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
6. The Developing Venous System
Vitelline
Umbilical
Cardinal
Subcardinal
Supra cardinal
Supra-Subcardinal
Anastomosis
Sinus
Venosus
7.
8.
9. EMBRYOLOGY
Formed by vasculogenesis.
3 vital systemic venous drainage - VITELLINE/ UMBILICAL/ CARDINAL
SINUS VENOSUS - RIGHT AND LEFT HORNS - Provide bilateral
connection
The connection of 3 veins on left side regress- CORONARY SINUS
When sinus venosus fail to regress- Persistent left superior vena cava
10. Remodeling of Abdominal Venous System Occurs
through Obliteration of the Left Supracardinal Vein
11. Failure of Left Cardinal Veins to Undergo Normal
Regression Leads to Venous Anomalies
LSVC occurs in 0.3% to 0.5%
of the normal population
In 65% of cases, left
brachiocephalic vein is also
missing
4% of patients with CHD have
an LSVC
Usually drains to the coronary
sinus
13. TRIBUTARIES TO CORONARY SINUS
1. The Great Cardiac Vein (v. cordis magna; left coronary vein)
2. The Small Cardiac Vein (v. cordis parva; right coronary vein)
3. The Middle Cardiac Vein (v. cordis media)
.4. The Posterior Vein of the Left Ventricle (v. ventriculi sinistri)
5. The Oblique Vein of the Left Atrium(oblique vein of Marshall)
6. The Right Marginal vein
14. Brachiocephalic trunk
Lt. common carotid A.
Brachiocephalic veins
Lt. subclavian A.
Ligamentum arteriosum
Ascending aorta
Superior vena cava
Aortic arch
Pulmonary trunk
Left pulmonary
artery
Right coronary artery
Left
pulmonary
veins
Left coronary artery
Marginal artery
Small
cardiac vein
Circumflex artery
Great cardiac vein
Anterior interventricular
(left anterior descending)
artery
15.
16. Coronary sinus
Inferior vena cava
Lt. pulmonary
vein
Rt. Coronary A
Posterior cardiac
vein
Middle
cardiac
vein
Posterior
interventricular A.
Right
ventricle
Left ventricle
19. GREAT CARDIAC VEIN
The GCV curves to the left as it leaves the anterior interventricular
groove, to form the base of the triangle of
‘‘ Brocq and Mouchet ”
Left anterior descending and the left circumflex arteries form other
sides.
GCV related internally to the anterolateral commissure of the mitral
valve.
The latter part lay in close relationship to the left circumflex artery
After crossing the left circumflex artery, the great cardiac vein ended
at the Vieussens valve and continued as the coronary sinus
20.
21. GREAT CARDIAC VEIN
Patent SVGs and
a patent LIMA to
the 1st diagonal
branch of the LAD.
.
Inadvertent
insertion of the
LIMA skip graft
into the Great
cardiac vein,
instead of the
distal LAD
22.
23. GREAT CARDIAC VEIN
Introducing the cardioplegic solution via the coronary
sinus will not perfuse the entire left side of the heart.
Post operatively there will be some myocardial
dysfunction due to non perfusion of the area drained
by Great cardiac vein.
Since the opening of the great cardiac vein in the right
atrium is very close to the interatrial septum it may be
mistaken as an atrial septal defect during cardiac
catheterization
24.
25. Selective arterialization of coronary
venous system
CVBG – Therapeutic option in patients with diffuse coronary artery
disease.
Arterial blood can perform retrograde perfusion through it and
nourish ischemic myocardium.
It helps to ensure sufficient blood flow, reduced thrombosis and
improved graft patency.
Another reason to select middle cardiac vein for arterialization was
that left coronary artery trunk or its branches may lie on the surface of
great cardiac vein for nearly 50% patients.
It means that, when coronary atherosclerosis happens, great cardiac
vein may be oppressed by sclerotic left coronary artery trunk or its
branches,
26. THEBESIAN VENOUS SYSTEM
In the absence of both
LSVC and a Coronary sinus
ostium in the left
atrium, drainage occurs
through enlarged Thebesian
veins.
Also, when hypoplastic
cardiac veins fail t o join t h
e coronary sinus, they
empty individually into the
atrial chambers through
dilated Thebesian channels
30. TRIANGLE OF KOCH
.
CORONARY SINUS DILATATION
1. Cardiac arrhythmia due
to stretching of the
atrioventricular node and
bundle of His.
2. Obstruction of the left
atrioventricular flow
because of partial occlusion
of the mitral valve.
a
31.
32. CORONARY SINUS
The coronary sinus is defined as the blood conduit that is a continuation of the great cardiac
vein from the valve of the great cardiac vein to the ostium of the coronary sinus.
The length varies from 3 to 5.5 cm. CS lies in the sulcus between the left atrium and ventricle
Begins proximally at the right atrial orifice and ends distally at the valve of Vieussen's.
.
The CS receives blood from the ventricular veins during ventricular systole and empties into the
right atrium during atrial systole.
The wall of the CS is made up of striated myocardium that is continuous with the atria, forming
a myocardial sleeve around the venous system
The Thebesian valve is a crescent shaped structure often found guarding the mouth of the CS
as it opens to the right atrium.
33. THEBESIAN VALVE
(1) absent, 14.7%;
(2) small and crescentric,
38%;
(3) large and covering the
entire orifice of the coronary
sinus, 30.7%;
(4) bars and bands, 5.3%;
(5) threads and networks,
5.3%;
(6) common Eustachian
and Thebesian valves,
34. RETROGRADE CARDIOPLEGIA
(1) the provision of a relatively uniform distribution of cardioplegia
even in the presence of severe coronary artery disease
2) it is effective in the presence of aortic regurgitation
(3) Redo – CABG antegrade cardioplegia is associated with a high
risk of atheromatous embolization from patent grafts
(4) RCP may be an effective method for treating coronary air
embolism
(5) it can be given without interrupting the surgical procedure.
35. Coronary Sinus ANOMALIES
An Absent coronary sinus is always
associated with a persistent left
superior vena cava (PLSVC)
connecting to the left atrium.
A Hypoplastic coronary sinus
occurs when one or more of the
cardiac veins drain directly into the
atria.
Atresia or stenosis of the coronary
sinus ostium may occur alone or with
associated cardiac anomalies
Enlargement of the coronary sinus
can be divided into two groups
- with left to right shunt
- without left to right shunt
Unroofed coronary sinus anomaly
36.
37. CORONARY SINUS ASD
Located – posteriorly and inferiorly in the interatrial septum.
INTERATRIAL SEPTAL TISSUE – separates AV valve
annulus.
May be associated SECUNDUM ASD.
CLEFT MITRAL VALVE- confluent PRIMUM ASD
PULMONARY VEINS – enter left atrium more superiorly than
usual – when LSVC present with coronary sinus ASD.
Left to right or right to left shunt depending on relative
ventricular compliance/ right atrial pressure.
38. Figure 1. Transesophageal echocardiography revealed both atrial and right ventricular
enlargement (left), a defect of the partial coronary sinus (middle), and shunt of the left atrium
to the dilated coronary sinus (right) at the near longitudinal plane.
41. REPAIR OF CORONARY SINUS ASD
Goal – separate systemic & pulmonary return
- eliminate shunting at atrial level
Caution – close to conduction system and pulmonary veins.
ROOFING PROCEDURE - BICAVAL VENOUS CANNULATION
- STANDARD RIGHT ATRIOTOMY
IF ATRIAL SEPTUM INTACT- FOSSA OVALIS IS INCISED
UNROOFED CS- MEDIAL TO PULMONARY VEINS
PERICARDIAL PATCH USED TO COVER THE DEFECT
ATRIAL SEPTUM REPAIRED EITHER PRIMARILY OR WITH
SECOND PERICARDIAL PATCH
42. UNROOFED CORONARY SINUS SYNDROME
LSVC to left atrium with coronary sinus ASD
LSVC to left atrium with COMMON ATRIUM
Complete unroofing without LSVC
Partial unroofing –mid portion without LSVC
Partial unroofing –distal portion ,no LSVC
Partial unroofing –distal portion ,intact
corsinus ostium with coronary sinus ASD
43. LSVC
PLSVC, is a result of a residual left
anterior cardinal vein.
It occurs in 0.1% to 0.3% of the
general population.
PLSVC is 3% to 8%, and up to 40%
when such patients have abnormal
situs
A PLSVC originates from the
junction of the left innominate vein
and the left jugular vein.
More than 90% of cases of PLSVC
drain through a coronary sinus.
44. The rest drain into the coronary sinus
through a window into the left atrium,
directly into the left atrium or into the
left pulmonary vein .
In 60% of cases, the innominate vein
bridges the two superior venae
cavae;
In the other 40%, the cavae drain the
right and left brachiocephalic regions
separately.
If there is no innominate vein the
PLSVC must persist; however, the
converse is not true.
A PLSVC with an absent right
superior vena cava is found in 14% of
cases
45. Questions to be asked
Is there a right superior
vena cava?
Is the Innominate
vein present
Is the PLSVC associated
with any other cardiac
malformations?
Where does the PLSVC
drain?
And does the surgery
involve the right atrium?
47. LSVC with CS Ostial atresia
Physiologically benign
Grave hazard- for cardiac surgeon if not identified
Permanent/temporary occlusion or vigorous
manipulation – cause myocardial congestion/ischemia
Patency should be sought – preoperatively/intraop
48. LSVC TO CS WITHOUT ATRESIA
If large left innominate vein is present – tourniquet.
Small/absent innominate veinCardiac catheterisation – occlusion pressure less than
18 mm hg- temporarily occluded.
Third angled venous cannula – cannulated directly
When temporarily occlusion not advisable
Flexible venous cannula retrograde through CS
Use of cardiotomy sucker.
Single right atrial venous cannula + profound
hypothermia and total circulatory arrest
49. LSVC TO LA without CS
LSVC can be ligated below innominate vein.
LSVC to RIGHT ATRIUM
- direct implantation
- left atrial tubular flap creation
- right atrial tubular extension
- PTFE graft
limitation – stenosis /occlusion of rerouted LSVC
50. COMMON ATRIUM
Repositioning the ATRIAL SEPTUM
-- Interatrial septum- completely excised
-- autologous pericardium/ prosthetic
patch used
Goal – systemic venous orifice lie on right side
- pulmonary venous orifice lie on left side
- optimal baffle placement
52. ATRIAL ISOMERISM
When b/l morphologically Right atria present
Lsvc enters the left sided Right atrium
Not an example of Unroofed coronary sinus.
Right isomerism – CS usually absent
Minor venous channel open directly into RA/RV
53. RAGHIB SYNDROME
INCLUDES – LSVC to left atrium
- Absence of coronary sinus
- Low lying ASD
Simple closure – Persistent desaturation
Correction - ASD repair + ligation of LSVC
- Excision of septum primum
- Placement of intra atrial baffle
54. HEART LUNG TRANSPLANT
Recipient LSVC is divided near its entrance
into left atrium during recipient cardiectomy
It is sutured end to end to donor left inominate
vein
SUPERIOR ROOFING – defect made in
interatrial septum
Superior wall of left atrium is used to make left
atrial tunnel from LSVC orifice to interatrial
defect
55. Cor Triatriatum
Pathogenesis - Impingement of a left superior
vena cava on the developing left atrium.
Left and right pulmonary veins may enter the
left atrium more superior than usual.
Mild to moderate narrowing- left atrium to which
pulmonary veins are attached.
56. Partially unroofed CS
condition can be easily overlooked
suspicious- when no asd or pulmonary vein
anomaly seen in RA with documented oxygen
step up
Diagnosis – pass a probe in CS orifice
- View defect through separate
incision in interatrial septum
FONTAN REPAIR - When it co exists with
tricuspid atresia – marked RIGHT to left shunt
that incorporates coronary sinus into systemic
venous pathway.
57. RECENT ADVANCES
Clinical trials investigating treatment with angiogenesis factors and gene therapy have been
goin on
New devices for creating cardiac arteriovenous fistulas percutaneously have been deviced
Radionuclide cardioangiography.
Three different systems of percutaneous mitral annuloplasty are currently under evaluation:
the Edwards Monarc system, the Carillon Mitral Contour System and the PTMA implant
system.
They are inserted into the coronary sinus and the great cardiac vein and all
work on the same principle: they shrink the mitral annulus, increasing leaflet coaptation and
thus reducing the regurgitation .
58. Take home message
Indications of selective CVBG include the patients with
tenuous right coronary artery or with diffuse lesions. It
is fit for the patients who need secondary CABG
operation.
Partially unroofed coronary sinus should not be
over looked
Close relation between LAD and GCV should
be kept in mind.