| Foreword: Cardiac Anesthesia |
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| Preface: Cardiac Anesthesia |
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| The Future of Cardiothoracic Anesthesia |
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207 | (10) |
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The future of cardiothoracic anesthesia, simply stated, depends on establishing and maintaining a unique and differentiated quality and identity that promotes and contributes positive value to patients, surgical colleagues, and health system administrators who are all also responsible for seeking value. |
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Cardiovascular anesthesiologists must therefore be prepared to define their value through demonstrating that unique quality. |
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To do this, they must codify and continue to push the leading edge in education, research, and clinical innovation for the subspecialty of anesthesia and thereby ensure a role in defining true value as the best. |
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| Generating New Knowledge in Cardiac Interventions |
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217 | (32) |
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Cardiac interventions are among the most quantitatively studied therapies. |
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It is important for all involved with cardiac interventions to understand how information generated from observations made during patient care is transformed into data suitable for analysis, to appreciate at a high level what constitutes appropriate analyses of those data, to effectively evaluate inferences drawn from those analyses, and to apply new knowledge to better care for individual patients. |
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| Quality, Patient Safety, and the Cardiac Surgical Team |
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249 | (20) |
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After more than a decade of attention, the risks inherent in cardiac surgery have been well documented, but examples of effective interventions to reduce this risk remain scarce. |
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The need is great, because the patient population is vulnerable and the potential consequences of poor outcomes are ever present and significant. |
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This article reviews a decade of discussion surrounding quality and safety issues in cardiac surgery, and concludes with examples of strategies that have shown great promise for improving cardiac surgery quality and safety. |
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| Fluid Management in Cardiac Surgery: Colloid or Crystalloid? |
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269 | (12) |
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The crystalloid-colloid debate has raged for decades, with the publication of many meta-analyses, yet no consensus. |
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There are important differences between colloids and crystalloids, and these differences have direct relevance for cardiac surgical patients. |
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Rather than asking crystalloid or colloid, we believe better questions to ask are (1) High or low chloride con-tent? and (2) Synthetic or natural colloid? |
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In this paper we review the published literature regarding fluid therapy in cardiac surgery and explain the background to these two important and unanswered questions. |
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| Ischemic Mitral Regurgitation: Mechanisms, Intraoperative Echocardiographic Evaluation, and Surgical Considerations |
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281 | (18) |
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Ischemic mitral regurgitation (IMR) is a subcategory of functional rather than organic, mitral valve (MV) disease. |
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Whether reversible or permanent, left ventricular remodeling creates IMR that is complex and multifactorial. |
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A comprehensive TEE examination in patients with IMR may have important implications for perioperative clinical decision making. |
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Several TEE measures predictive of MV repair failure have been identified. |
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Current practice among most surgeons is to typically repair the MV in patients with IMR. |
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MV replacement is usually reserved for situations in which the valve cannot be reasonably repaired, or repair is unlikely to be tolerated clinically. |
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| Robotic and Minimally Invasive Cardiac Surgery |
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299 | (22) |
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The transition of mitral valve surgery away from the traditional sternotomy approach toward more minimally invasive strategies continues to evolve. |
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The use of telemanipulative robotic arms with near 3-dimensional valve visualization has allowed for near complete endoscopic robotic-assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. |
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Studies have shown rapid recovery times without sacrificing perioperative safety or the durability of surgical repair. |
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Although a steep learning curve exists as well as high fixed and disposable costs, continued technological development fueled by increasing patient demand may allow for further expansion in the use of robotic-assisted minimal invasive surgery. |
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| Advances and Future Directions for Mechanical Circulatory Support |
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321 | (34) |
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Although cardiac transplant remains the gold standard for the treatment of end-stage heart failure, limited donor organ availability and growing numbers of eligible recipients have increased the demand for alternative therapies. |
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Limitations of first-generation left ventricular assist devices for long-term support of patients with end-stage disease have led to the development of newer second-generation and third-generation pumps, which are smaller, have fewer moving parts, and have shown improved durability, allowing for extended support. |
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The HeartMate II (second generation) and HeartWare (third generation) are 2 devices that have shown great promise as potential alternatives to transplantation in select patients. |
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| Transcatheter Aortic Valve Replacement |
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355 | (28) |
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The percutaneous transcatheter aortic valve replacement (TAVR) procedure, introduced in 2002, has emerged as a successful and comparable treatment option for many patients with aortic stenosis. |
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Balanced general anesthesia or monitored anesthesia care in addition to local anesthesia have been used during transfemoral and transapical approaches. |
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The results of different TAVR registries and the PARTNER trial have shown excellent success and survival rates, but stroke and paravalvular insufficiency represent major concerns. |
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The key for successful procedural out-come involves thorough preparedness and knowledge of the pertinent procedural details. |
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| A Review of Cardiac Transplantation |
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383 | (22) |
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Perioperative anesthetic management for cardiac transplantation is reviewed. |
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Recent developments in adult cardiac transplantation are noted. |
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This review includes demographics and historical results, recipient and donor selection and evaluation, mechanical circulatory support and heart transplantation techniques, and patient management immediately postimplantation. |
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| Anesthetic Considerations for Adults Undergoing Fontan Conversion Surgery |
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405 | (16) |
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There are currently in North America more adults with congenital heart disease than children. |
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This article discusses the anesthetic considerations in adults with single-ventricle physiology and prior repairs who present for Fontan conversion surgery as a demonstration of the challenges of caring for adults undergoing interventions for the repair of congenital heart defects. |
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The care of these patients requires an understanding of the impact of passive pulmonary blood flow and single systemic ventricular physiology. |
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The perioperative morbidity in this patient population remains high. |
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| Critical Care of the Cardiac Patient |
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421 | (12) |
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As the spectrum of cardiac surgeries has grown, the diversity and complexity of postoperative cardiac surgical care has also increased. |
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This article examines 4 areas in critical care where clinical practice is evolving rapidly. |
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Among these are management of mechanical ventilation, thresh-olds for blood transfusion, strategies for hemodynamic monitoring, and processes for central line insertion. |
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Also reviewed are current approaches to common dilemmas in postoperative cardiac care: diagnosis of tamponade, and the diagnosis and management of low cardiac output states in patients with a ventricular assist device. |
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| Blood Management |
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433 | (18) |
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Blood management is a system-based comprehensive approach that uses evidence-based medicine to facilitate an environment to encourage an appropriate use of blood products in the hospital setting. |
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The ultimate goal of a blood-management program is to improve patient outcomes by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. |
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It is a patient-centered, multidisciplinary, multimodal, planned approach to the management of patients and blood products. |
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| Thoracic Endovascular Aortic Repair: Update on Indications and Guidelines |
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451 | (28) |
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Thoracic endovascular aortic repair (TEVAR) has revolutionized thoracic aortic surgery and has increased the options available to the aortic specialist in treating thoracic aortic disease. |
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TEVAR is less invasive, and is associated with a decrease in perioperative morbidity and mortality when compared with open surgical repair. |
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The dramatic expansion of TEVAR activity has necessitated a better definition for the indications, contraindications, and limitations of this new technology. |
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Ideally TEVAR should be performed in specialized aortic centers providing a full range of diagnostic and treatment options, using a multidisciplinary team approach. |
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| Anesthetic Considerations for Electrophysiologic Procedures |
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479 | (12) |
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The array of diagnostic and therapeutic procedures performed in the cardiology electrophysiology laboratory has expanded rapidly. |
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Increasingly more facilities and cardiologists are performing these procedures, and the number of patients for whom these procedures are indicated is expanding. |
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Because of the complexity of the procedures and associated patient comorbidity, anesthesia providers will become more involved in providing care in the electrophysiology laboratory. |
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Therefore, anesthesia providers must be prepared to handle a broad range of case complexity. |
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This article addresses the implications of providing anesthesia safely and effectively in the electrophysiology laboratory. |
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| Index |
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491 | |
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