This document discusses the Bentall procedure for treating type A aortic dissection and revisits its use. It provides an overview of the history and anatomy relevant to the procedure. It then summarizes some studies comparing outcomes of the Bentall procedure versus the Ross procedure or valve-sparing surgery for acute type A dissection. The document concludes that the Bentall procedure remains a safe and less painful option for aortic root dissection with reasonable outcomes when the coronary buttons are properly placed.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Chronic Total Occlusions: The Road Less TraveledAllina Health
By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.
Complication on avf play significant number of hospitalization & morbidity. Despite fistula first campaign are still beneficial for most patient, gathering knowlege to prevent complication are important.
simple word for future doctor. writing & drawing in pure white paper is always fun & feels like nothing to loose even if we knew that it will last almost forever
in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno
Acute type A dissection, is on of the highest mortality cases in cardiovascular surgery. It doubled it incident with concomitant complication such as malperfusion or pericardial tamponade. In this presentation, the patient have both coronary malperfusion and pericardial tamponade
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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.
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
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 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.
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
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
9. • Complete replacement of Aortic Root & Valve,
with re-implantation of the coronary arteries
into the graft
• Hugh Bentall & Antony De Bono
• London 1968
10. The anatomy of the
sinus of Valsalva
Kenneth Reid
Thorax 1970 25: 79-85
doi: 10.1136/thx.25.1.79
15. What is the better choice for acute type A dissection
Bentall vs VSSR
Author N
B/VSSR
Mean
f/u
survival Event free
survival
Bernhard A., Reichenspurner et
al.
2011
30/58 3.2 y 14Y-87% B
14Y-89%VSSR
14Y-48% B
14Y-44% VSSR
Freedom from
Reoperation
Bekkers JA, Boggers Ad et al
2012
75/157 7.2 Y Overall 10y-
53.4% without
significant
difference
10y-100% B
10Y-85% VSSR
without
significant diff.
Subramanian S, Mohr FW et al
2012
130/78 7.2Y Overall 8y-55%
without
significant diff
Overall 8y-95%
without
significant diff.
16. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases
30mm = Aneurysm
>55mm = Surgery
>50mm = Bicuspid
>45mm = Marfan
19. Outcomes 15 Years After Valve
Replacement With a Mechanical Versus a Bioprosthetic Valve: Final RCT on hogh rist pts
Ann Thorac Surg 2014;76:698–703
20. Kaplan-Meier curves
of event-free survival
Kaplan-Meier curve of survival
Outcomes 15 Years After Valve
Replacement With a Mechanical Versus a Bioprosthetic Valve: Final RCT on hogh rist pts
Ann Thorac Surg 2014;76:698–703
24. General considerations
• Establishing CPB in traditional way.
– W/o cross clamping
– Rt radial a. line/ femoral a. line opposite to
cannulation site.
– Routine TEE
• If FEM-FEM bypass is chosen.
– CFA with the most normal pulse
– CFV on the right should be used ( easily
positioned to RA )
26. Axillary Cannulation
Advantages Disadvantages
• Antegrade perfusion.
• No manipulation of the ascending
aorta.
• Recomended over femoral
cannulation as prophylaxis against
malperfusion, lower extrmity
ischemia,retrograde dissection and
retrograde embolization of debris
• Time consuming.
• Impossible to CNS perfusion
if dissected.
• Brachial plexus injury.
• Vascular complication.
Axillary artery cannulation in type A aortic dissection
operations. J Thorac Cardiovasc Surg 1999
Axillary cannulation in acute ascending aortic dissections
Ann Thorac Surg 2000
27. • On Bypass… temp 28.. VF
• (Clamp)… Aortotomy
• Composite implantation
• L-button
• Temp 22’C.. HCA
• Open distal anastomosis
• Re warm.. Aortic Clamp… R button
35. Results
• No difference in late all cause mortality
The Addition of the Hemi‐Arch Replacement to Aortic Root Surgery does NOT increase Operative Mortality
Badiwala M, Rinewalt D, Kruse J, Li Z, Andrei AC, McCarthy PM, Malaisrie SC. 2014
Addition of a hemi-arch replacement using DHCA to the
modified Bentall Procedure does not significantly increase
stroke and bleeding complications, nor mortality
44. Meta Analysis Harapan Kita**
Total Adjust* Total Adjusted*
Bleeding Redo 18 1.4 22 2.1
Cardiac
3rd block 2.1 1.4 3 1
Inotropic Supp 56 21 76 18
VF 11 0.7 5 0
Respiratory 22 2.8 23 2
Chronic Dialysis 9 1.7 11.2 0
Infection 11 1.7 33 4.2
Mortality 22 1 18.8 1
Mean LOS 18 13.3 29 15
Ann Thorac Surg 2014;76:698–703
*Adjusted for unstab preop, multiple comorbidity, multiple procedures, redo bentall, conversion
** Data 2013-2016
45. • Conclusions
• Bentall for Root Dissection, is a safest & less
painfull option, with reasonable outcome
• Timing of Surgery, & placement of coronary
button is one of the most contributing factor
• There are few option for managing fragile
tissue
Editor's Notes
Kaplan-Meier curve of survival of all patients after the Ben- tall operation (solid line). Overall survival is 0.95 (95% confidence intervals, 0.9 to 0.99) at 5 years and 0.93 (95% confidence intervals, 0.86 to 0.99) at 8 years. Shown for comparison is an age-matched and sex-matched curve for the US population (dotted line)
Kaplan-Meier curves of event-free survival among the 142 patients who underwent a Bentall operation. Events include endocar- ditis, need for ascending aorta reoperation, stroke, or significant thromboembolic or bleeding complications (requiring hospitaliza- tion). Event-free survival is 0.85 (95% confidence intervals, 0.78 to 0.92) at 5 years and 0.78 (95% confidence intervals, 0.68 to 0.88) at 8 years.
Excessive bleeding after aortic surgery is generally related to a combination of several alterations in the hemostatic system pertaining to the dilution and activa- tion of the coagulation system, which is mainly attributed to the use of extracorporeal circulation.
The repair of spontaneous dissecting aortic aneurysms or iatrogenic aortic dissections can be very complex because of the extreme friability of the aortic tissue, the extent of damage to structures, and in many cases, secondary organ involvement [1, 2]. Many techniques have been used to reinforce the friable aortic tissue. Teflon felt has been amply used, but many times the resultant aortic cuff is tough and of small size. Bleeding from this graft– “sandwiched” aorta can be troublesome. Resorcinol glue, although extremely useful to reinforce the aortic tissues [7, 8], is not available in the United States. Topical 25% glutaraldehyde, as described by Vasseur and Hamond [9] for dissecting aneurysms and later by us for friable aortas [10], is very effective in toughening aortic tissue. How- ever, the procedure of applying the glutaraldehyde is tedious, and it can damage the surrounding tissue.
The adventitial inversion technique described by Flo- ten and colleagues [3] is an effective method of modifying the friable aorta to create a tough but soft aortic cuff. The toughness ensures that the sutures hold without tearing. The softness allows the use of small needles and sutures to facilitate a hemostatic anastomosis. Their remarkably
low (7.1%) mortality [3] alerted us to the versatility of this technique.
Dissecting aneurysms can create practically unsolvable surgical situations. Our experience expands the use of the adventitial inversion technique to other complex surgical situations. Thus, most patients can be handled with the techniques outlined here. None of the 11 aortic cuff–graft anastomoses bled intraoperatively or postop- eratively.
We recommend this simple technique to repair dis- secting aneurysms, because it has changed our percep- tion and approach to this highly complex problem. Our experience is small; thus, it is difficult to draw meaningful conclusions about the universal applicability of the tech- nique and long-term results. However, in 1995, Floten and colleagues [3] had treated 29 patients with excellent results in the short- and long-term follow-up.
However, there are some experimental reports suggesting that, due to the extrinsic coagulation pathway via exposed adventitial collagen and tissue factor, inverted adventitia may elicit thrombus formation with subsequent emboliza- tion,4) although the thrombogenicity of inverted adventitia has not been tested clinically to our knowledge. Wishing to address this technique’s advantages and its potential complications, we integrated this method with our method of telescopic graft insertion.5) This resulted in complete coverage of the inverted adventitia, eliminating the potential risk of thrombus formation. Furthermore, reinforcement of the intima by two adventitial layers, an external felt strip, and tube graft (Fig. 1C) lead to com- plete hemostasis, eliminating the need for hemostatic stitches and resulting in stable anastomosis.
Resection of the aortic arch and ascending aorta was undertaken and a Dacron tube graft was used as a replace- ment conduit. Felt or BioGlue was placed between the intima and adventitia to obliterate the false lumen and recreate a neo-media (Fig. 1). Hemiarch repair was used in 96 patients, and an extensive or total aortic arch replacement (elephant trunk procedure) was used in 8 patients. The primary tear site was resected in all patients. On completion of the aortic arch reconstruction, blood was allowed to occupy the native aorta and graft, allowing air and debris to be evacuated from the cerebrovascular system. The entire arterial circulation was deaired at this time via the RCP circuit. The arch graft was cannulated and then proximally cross-clamped, with RCP termination and resumption of arterial perfusion and rewarming directly through the aortic arch graft for antegrade perfusion.
The aortic root was replaced or repaired depending on the pathology present. When repair was deemed possible, the aortic valve leaflets were resuspended using three pledgeted supracommissural sutures. The sinus of Valsalva segments were then reinforced with Teflon felt as a neo-media (Fig.
Figure 1. Application of felt “neo-media” placed between adventitia and intima.
2), and more recently BioGlue was used as an adjunct. In 81 patients, the aortic root was repaired, and in 23 patients the aortic root was replaced with either a biologic or a mechan- ical valved conduit (see Table 2). Indications for the re- placement of the aortic root included bicuspid aortic valve (n 9), Marfan syndrome (n 10), Ehlers-Danlos syn- drome (n 1), primary abnormalities of the aortic valve leaflets, obvious sinus of Valsalva aneurysm, and extension of both the tear and dissection to the aortic annulus (see Table 2). TEE was used in all patients to assess the ade- quacy of the aortic root repair
All patients received 1 g methylprednisolone (Solu-Medrol) intravenous bolus, 1 g MgS04 intravenous, 2.5 mg/kg lidocaine intrave- nous, and 12.5 g mannitol intravenous. These neuroprotec- tive agents were given immediately before initiation of CPB
In conclusion, our data show improved survival and low postoperative stroke rates with the use of an integrated perioperative approach to acute type A dissection. Together, these measures create a new paradigm that consists of:
1. Rapid admission to the operating room for diagnosis and therapy
2. Intraoperative TEE3. Neurocerebral monitoring4. Routine open aortic arch reconstruction with RCP5. Routine antegrade arch graft perfusion after comple-
tion of arch repair6. Aortic root repair and aortic valve resuspension in most
patients when preexisting leaflet or root pathology is absent 7. Creation of a neo-media using either felt or BioGlue to
New Paradigms for Acute Type A Dissection 341 strengthen the aortic and sinus walls and obliterate the false
lumen.
Persistent oozing and bleeding after aortic anastomosis can occur during aortic surgery. This may become uncontrollable because of severe coagulopathy, resulting from induced hypothermia, long cardiopulmonary bypass time, or fragile aortic walls by acute aortic dissection. There are a lot of methods used to prevent this bleeding, such as anastomosis techniques to reinforce a suture line, Bioglue (CryoLife Inc, Kennesaw, GA) for anastomosis, or wrapping methods, such as the Cabrol shunt, which have been reported [1–3]. However, these techniques are not always perfect and are too complex to perform for every anasto- mosis during a tough operation. In this report, we describe a novel wrapping technique with insertion of fat tissue between the anastomotic site and the Teflon felt (DuPont, Wilmington, DE), which is a simple, effective, and reliable technique, and should be useful to obtain perfect hemosta- sis on the suture line.
Enough fat tissue is harvested, sometimes around the peripleura under the divided sternum. The thickness and width of harvested fat should be adjusted to bleeding conditions. The thickness of 1 mm is enough to be an even suture line like graft-to-graft anastomosis. However, 3-mm to 4-mm thickness is necessary to completely seal a bumpy surface after placing some stitches and pledgets. The width of 1-cm to 2-cm is enough to cover bleeding points.
hen, harvested fat tissue is placed on a Teflon felt strip (DuPont) or a used prosthetic graft, which is 1.5-cm to 2.0-cm wide, and fixed to these using some interrupted stitches by a 5-0 Prolene suture (Ethicon, Somerville, NJ). Finally the anastomotic portion including bleeding points is wrapped by this composite felt. We can control the applied pressure by using our fingers, which will immediately reduce the bleeding. Then, both ends of the felt strip are tightened using interrupted sutures after confirming a perfect hemostasis (Fig 1).
Report persistant fistula.. N RV failure.. Repair after 4 month
6mm goretext
In aortic operations, we routinely enter the pericardial space by incising the pericardium along the border of the right pleural space and hang it to the left sternal half with stay stitches in order to prepare a patch of pericardium, measuring roughly 22 inches when needed for a peri- graft to right atrial fistula (Fig 1).
It is important to close the transverse sinus to prevent posterior leakage in first-time operations. For this pur- pose posterior wall of the left atrium can be sewn to the anterior aspect of the right pulmonary artery by taking shallow bites. For redo operations, it is not necessary to close the transverse sinus, because of the adhesions.
We use 5/0 polypropylene for construction. Inferiorly, suturing starts at the epicardium of the right ventricular wall, continues towards the main pulmonary artery by taking bites from the adventitia. The Teflon felt at the distal suture line constitutes the superior border of the patch (Fig 2). Medially sutures can be placed to the posterior pericardium and then to the lateral aspect of the superior vena cava towards the base of the right atrial appandage (Fig 3). Care should be taken to avoid injury to the sinus node.
Before completing the suture line, a large stab wound is created on the medial aspect of the right atrium and this hole is enlarged with the tip of a forceps. The perigraft space is then closed expeditiously (Fig 4).
One patient with the right coronary ostium dissection required coronary artery bypass grafting. The proximal anastomosis of the vein graft was constructed to the right brachiocephalic artery after creation of the shunt.
The decision to construct a shunt was made when significant bleeding persists about 20 to 30 minutes after the administration of protamine, despite the transfusion of fresh frozen plasma (FFP), fresh whole blood, throm- botic agents, and mechanical packing
Hoover and associates [2] preferred graft interposition instead of a direct shunt, because the grafts may be more likely to thrombose and if not, they can be embolized with coils. Cabrol and associates [5] reported persistent left to right shunt in 3 of 260 shunt procedures.