Seminars in thoracic and cardiovascular surgery
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The purpose of this paper is to review the current literature and practice of the Ross concept of using the autologous pulmonary valve to replace a diseased aortic valve. The potential advantages and disadvantages of these operations will be evaluated in the context of alternative options and relative risks. ⋯ Long-term outcomes will be described to the extent these are available, including recent publications describing a survival advantage for the Ross. Brief discussions will be presented regarding hemodynamics, child-bearing, endocarditis, and the use of the Ross in pediatric patients as well as biological adaptability of the living pulmonary autograft.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2011
ReviewWatchful waiting for severe mitral regurgitation.
Watchful waiting is an established treatment strategy for asymptomatic patients with severe organic mitral regurgitation. It is based on indications for surgery that are based on current European Society of Cardiology and American Heart Association/American College of Cardiology guideline recommendations, which are defined by symptom onset, impairment of left ventricular function, and left ventricular enlargement. ⋯ There is an ongoing debate about whether surgery should be performed in asymptomatic patients with preserved ventricular function. Ultimately, decision-making needs to be individualized and to take individual patient-related factors and local resources (including the natural history of the disease, the risk of surgery, and the likelihood of successful mitral valve repair) into consideration to obtain an optimal outcome with medical and surgical management.
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Determining the optimal level of glycemic control in critical illness has proven difficult since the original Leuven study conclusions were published in 2001. Conflicting evidence, scientific methodologies, hospital cultures, and a-priori biases have challenged many clinical practice patterns. Specifically, the prioritization of patient safety has resulted in many practitioners changing from a glycemic control target of 80-110 mg/dL to a more liberal target of 140-180 mg/dL. ⋯ This position paper presents an approach for cardiac surgery patients in the intensive care unit (ICU) consistent with extant evidence and real-life variables. We argue that in the cardiac surgery ICU, glycemic targets may be as low as 80-110 mg/dL when formal intensive insulin therapy and nutrition support protocols are used with low rates of hypoglycemia, patient safety mechanisms, properly trained staff, and a supportive hospital administration all in force. Cardiac surgery ICUs that already follow this model may continue with 80-110 mg/dL blood glucose targets, whereas others may advance their blood glucose targets in a stepwise fashion: from 140 to 180 mg/dL to 110-140 mg/dL to 80-110 mg/dL, on the basis of their performance.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2011
Increasing the lung donor pool: recruitment of the gift of life.
Lungs suitable for organ donation are a scarce resource. Recent efforts with alternative ventilatory strategies have yielded promise to the potential expansion of lungs suitable for transplantation.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2011
Chest physiotherapy in lung resection patients: state of the art.
The role of chest physiotherapy in limiting postoperative pulmonary complications and in the recovery of pulmonary function and exercise capacity after lung surgery is still unclear because of the lack of conclusive, well-designed clinical trials. In this article the available literature on these topics is reviewed, and the effects of respiratory physiotherapy, instituted preoperatively or administered after surgery to patients undergoing lung resection, are commented on. ⋯ Also physiotherapy administered during the immediate period after lung resection probably decreases frequency of pulmonary complications. Finally, further investigation is required for a better understanding of the effects of long-term chest physiotherapy after hospital discharge in lung resection patients.