Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
Minimally invasive approaches to aortic valve surgery: Brigham experience.
Aortic valve surgery is a proven and effective therapy for severe aortic stenosis and insufficiency. Conventional aortic valve surgery is performed with a full sternotomy, cardiopulmonary bypass, and replacement of the diseased aortic valve. Unlike minimally invasive (or "off-pump") coronary artery bypass, minimally invasive aortic valve surgery still requires cardiopulmonary bypass but refers primarily to smaller incisions and access. ⋯ The upper hemisternotomy has become our standard approach to isolated aortic valve surgery. It is a safe and effective technique with a similar morbidity and mortality to conventional aortic valve surgery. Patients derive clear benefits from this minimally invasive approach including less pain, shorter length of hospital stay, and faster return to preoperative function levels.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewIntensive insulin therapy in high-risk cardiac surgery patients: evidence from the Leuven randomized study.
Mortality and morbidity of critically ill diabetic as well as nondiabetic patients are improved when blood glucose levels are tightly controlled to normoglycemia with intensive insulin therapy during their stay in the intensive care unit (ICU). This has been demonstrated in large prospective, randomized, controlled clinical studies for adult patients admitted to surgical and medical ICUs. Particularly for cardiac surgery patients, the hospital survival benefit with insulin therapy is most pronounced and maintained up to 4 years after hospital discharge, without inducing a substantial burden for the patients, their relatives, or society. Mechanistic studies exploring the molecular pathways involved suggest that intensive insulin therapy exerts its beneficial effects mainly through the maintenance of normal blood glucose levels.
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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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Surgical mitral valve repair is the procedure of choice to treat mitral regurgitation of all etiologies. Whereas annuloplasty is the cornerstone of mitral valve repair, a variety of other surgical techniques are utilized to correct dysfunction of the leaflets and subvalvular apparatus; in most cases, surgical repair entails application of multiple repair techniques in each patient. ⋯ Specifically, there has been great progress in the development of novel technology to facilitate percutaneous annuloplasty and percutaneous edge-to-edge repair. The objectives of this report were to (1) discuss the surgical foundations for these percutaneous approaches; (2) review device design and experimental and clinical results of percutaneous valve repair; and (3) address future directions, including the key challenges of patient selection and clinical trial design.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2006
ReviewAchieving tight glycemic control in the operating room: lessons learned from 12 years in the trenches of a paradigm shift in anesthetic care.
Intensive insulin therapy to control perioperative hyperglycemia has become the new standard of care for cardiac surgery patients. Although there are several published protocols for achieving tight glycemic control in the postoperative period, there are no such published protocols or even suggested methods for intraoperative control. At Providence St. ⋯ All four have evolved in the hands of experienced cardiac anesthesiologists. Each of these anesthesiologists was faced with the daily task of individualizing patient therapy with the common goal of eliminating intraoperative hyperglycemia. In this article we will describe each of these four generalized methodologies to give the practicing anesthesiologist a starting point from which they can develop and hone their own technique further.