International Children S Heart Fund

International Children’s Heart Fund

International Manual

of

Cardiothoracic Surgery

A. Thomas Pezzella MD, Editor

Founder/Director

International Children’s Heart Fund

Contact:

A. Thomas Pezzella MD

17 Shamrock St.

Worcester, MA 01605 USA

e-mail –

cell phone – 1-774-272-0241

Acknowledgements

To Harold Jeghers MD who inspired a generation of physicians to employ an organized system of collecting and indexing textbook, monograph, and journal subjects/articles into a readily available Index Filing System (cf Appendix)

To James I. Cox MD, the founder of the World Heart Foundation, for his vision and strategic planning in developing a model for bringing voluntary and humanitarian cardiothoracic surgery treatment, education, research, and services to a wider global population, as well as initiating the concept of open access to an internet based encyclopedia of cardiothoracic surgery.

To Shanghai Chest Hospital, for the opportunity to spend one year (July 2005- July 2006) in Shanghai, China on behalf of the World Heart Foundation to help initiate a model 6 year cardiothoracic residency program. This experience gained the editor insights into the daily needs of the international audience of Cardiothoracic Surgeons.

To Cho Ray hospital in HCM City, Vietnam, for also extending an invitation to implement a model 5 year CT surgery residency program from July, 2012 to January, 2013.

International Handbook

of

Cardiothoracic Surgery

Preface

The source of current knowledge, information, and techniques in cardiothoracic surgery is derived from major textbooks, monographs related to specific areas or topics, journals, product information, corporate exhibits, product representatives/personal, the internet, the plethora of local, regional, national, and international meetings, congresses, conferences, symposia, seminars, workshops, and the emerging teleconference, telemedicine, teleconsult vehicles. This internet based open access text is primarily oriented to medical students, general surgery and CT surgery residents, physician assistants, and all others interested in a ready source of the practical basics of cardiothoracic surgery, including adult cardiac, pediatric cardiac, and general thoracic surgery. Hopefully the international character and focus of the information will be useful to a worldwide audience. It is offered free to those desiring it, and especially those without ready access to the published literature. It will be updated annually, or more frequently at the discursion of the contributing authors. No financial gain is planned or desired. Feel free to contact the author with questions, objections, suggestions, and a willingness to contribute to future editions. The ultimate goal is to provide the international cardiothoracic community with free access to practical information for everyday use in the active practice of the full spectrum of Cardiothoracic Surgery.

A. Thomas Pezzella MD

International Manual of Cardiothoracic Surgery

Outline

Ⅰ General Topics

·Introduction

·History of Cardiothoracic Surgery

·Global Aspects of Cardiothoracic Surgery

·Risk/Quality Assurance/Cost/Database/ Coding(USA)

·Complications/Errors

·Standards/Guidelines- STS/AHA/ACC

·Evidence Based Medicine

·Statistics/Research-Development/Grants/Funding/IRB

·Education/Training/Credentials/Licensure/ECFMG/ Job Opportunities – CV info.

·Ethics/Finance/ Billing/ Malpractice/ Reimbursement

·Government/Societies/Organizations

·Internet/Library resources/Publications/Computers/Library resources/Open access

·Administrative/Logistical considerations

·Corporate/Industry.

·Product

·Information

·Cost: Donation/Discounted/Market value

·Education

·Relationship guidelines

.Contact information

Ⅱ Basic Considerations

·Anatomy/embryology

·Physiology

·Biochemistry

·Pathology – Anatomical/Clinical

·Pharmacology

·Microbiology/Molecular Biology

·Pathophysiology

·Genetics

·Preventive Medicine/Public Health

·Clinical evaluation

·Etiological Considerations: Trauma, Infection, Cancer, Congenital, Post-operative sequellae, Iatrogenic, Local manifestations of systemic disease, Combinations-coexistence

·Flow sheets/ Case flow/ Protocols

·Algorithms

·Formulas

Ⅲ Clinical Disciplines

·Cardiology – Clinical/Diagnostic/Invasive/Interventional/Nuclear/EPS

·Pulmonology – Pulmonary Function/Diagnostic/Endoscopy

·Oncology - Staging/ Chemotherapy

·Gastrointestinal/Endoscopy

·Hematology/Blood Bank

·Infectious Disease

·Immunology/Transplantation

·Neurology/ Psychological testing

·Psychiatry

·Pharmacology - Clinical

·Renal

·Endocrine/Metabolic

·Pediatrics

·Surgery, general surgery - specialties

·Intensivist (Pediatric ICU, Neonatal ICU, CCU, Medical ICU, Surgical ICU,
CT Surgery ICU)

·Emergency Room / Trauma

·Anesthesia

·Pathology (Anatomic/Clinical)

·Radiology - diagnostic/invasive/interventional

·Radiotherapy

·Perfusion technology

·Nursing (ICU, OR, Ward, Clinic, Special care areas)

·BLS/ ACLS/ ATLS/ PCLS

·Allied health areas (Respiratory/Rehab./Lab./Occupational/Radiology)

Ⅳ Patient Care

·Preventive/Public Health/Epidemiology

·Pre-operative – Indications/ Evaluation/ Diagnostic aspects/ Clinical pathways/ Risk

·Operative – Anesthesia/ Perfusion/ Nursing/ Logistics/ Equipment – Supplies/ Instruments/ OR design, systems

·Post-operative – Subsystem Approach (outline)

·Rehabilitation – Follow up care/ Residua/ Complications

·Results/ Outcomes

Adult Cardiac Surgery

·Coronary Artery Disease (cf. outline)

·Valvular Heart Disease/ Endocarditis (outline)

·Aorta – Root/ Ascending/ Arch/ Descending/ Thoracoabdominal

·Trauma – Blunt/ Penetrating/ Blast/ Iatrogenic

·Transplantation – Heart/ Heart-Lung/ Assist/ Bridge

·Tumors

·Pericardium

·Arrhythmias – Medical/ Surgical/Pacing

·Tissue engineering/ Gene therapy/ Stem cell

·Cardiomyopathy/↓LV

·Vascular Surgery

·Complications

General Thoracic (Adult/Pediatric)

·Preoperative/ Operative/ Postoperative considerations

·Trauma

·Cancer

·Infection

·Anatomical

·Chest wall

·Pleura

·Lung – Congenital/ Acquired/ Transplantation

·Tracheobronchial

·Thoracic spine

·Mediastinum

·Diaphragm

·Esophagus

·motor

·congenital

·trauma

·reflux

·cancer

·Complications

Pediatric Cardiac Surgery

·Epidemiology – Incidence/ Prevalence/ Etiology

·Fetal/Neonatal Physiology/Pathophysiology

·Morphogenesis

·Anatomical tables/ charts

·Clinical cardiology (NICU, PICU, Ward, Clinic, ER)

·Diagnostic

·ECG

·ECHO- TTE, TEE

·CT

·MRI

·Catheterization- invasive

·Interventional Cardiology

·Database/ Classification/ Scores/ Risk

·Preoperative aspects

·Operative aspects

·Anesthesia: Access, Airway, Anesthesia, Monitoring, Drug support

·Perfusion, ECMO

·PICU – postoperative care

·Outcomes—complications, results

·Specific Congenital Anomalies

·Isolated/combined disorders

·Conduits – Conduit disorders

·PDA

·Vascular Rings

·Coarctation

·Pulmonic stenosis

·Interrupted Arch/Hypoplasia

·ASD; PAPVR; other Atrial Anomalies

·VSD

·AV Canal

·Truncus Arteriosus

·AP window

·RVOTO

·Tetralogy Fallot- with/ without pulmonary atresia

·Pulmonary Atresia/VSD

·Pulmonary Atresia/intact septum

·DORV

·DOLV

·Double Inlet Left Ventricle

·Double Inlet Right Ventricle

·Single Ventricle- physiology/ pathway

·TGA

·cTGA

·Ebstein anomaly

·LVOTO

·HLHS

·AV/LV tunnel

·Congenital MV problems

·Straddling/Overiding AV valve

·TAPVR/Pulmonary Vein Stenosis/Cor Triatriatum

·Anomalies of Systemic Venous Connections

·Coronary Artery Anomalies·

·Dextrocardia/situs inversus

·Isomerism/Heterotaxy

·Takayusu

·Kawasaki

·Rheumatic Fever/Rheumatic heart disease

·Tumors

·Trauma

·Pericardium

·Transplantation/Assist

·Endocarditis

·Arrhythmias/Pacemakers

·Adult congenital heart disease

Appendices

·Index (Jegher’s)

·ABTS

·ECFMG

·websites

·Charts/Figures/Tables

·Formulas/ Equations

·Corporate contacts

·Pre-operative - orders

·Post-operative-orders

·Flowsheets

·Protocols

·Operative sheet

·Preference list (Pick List)

·Charting – ICU/Ward – Flow sheets

·Perfusion record

·Anesthesia record

·Resuscitation

·ACLS

·PALS

·ATLS

·Drugs- Anesthesia, cardiac, other

·Instruments – Basic – Adult Cardiac/Pediatric Cardiac/General Thoracic

·OR diagram

·ICU diagram

·Equipment/Supplies

·Medications

·Hospital Aspects – bricks/mortar; infrastructure

·Volunteer/ Humanitarian Efforts

Cardiac Valve Surgery

General Aspects /

Mitral Valve

· History
·Etiology
·Demographics
· Valve anatomy/ dynamics / · Mechanical
·Diagnostic modalities / · Bioprosthetic
·Surgical indications/ EBM/ Risk ACC-AHA Guidelines / · Leaflet/valve preservation techniques
·Statistical modalities/database / · Homograft
·Complications / · Deac procedure
·Results/outcomes / · Quattro
Operative Techniques / · RossⅡ
Approaches / · Repair - ring/band/other
·Annulus
·Leaflets
·Cords
·Papillary muscles
·Median sternotomy
·Mini sternotomy
·Clam shell
·Left chest
·Right chest / ·Infective Endocarditis
·Minimally invasive / ·Pediatric/Congenital (cf. congenital)
·Robotic technology /

Tricuspid

·Percutaneous, trans apical technology / ·Mechanical
Aortic Valve / Ascending Aorta / ·Bioprosthetic
·AVR (mechanical) / ·Repair - ring/band/other
·AVR (bioprosthetic) / ·Ebstein’s anomaly
·AVR - Stentless / ·Infective Endoacarditis
·Valve Sparring (David/Yacoub) / ·Pediatric/Congenital
·Bental (mechanical) /

Pulmonary Valve

·Replacement
·Excision
·Repair
·Conduit- homograft/heterograft/ Dacron/Other
·Pediatric/Congenital
·Bental (bioprosthetic)
·Freestyle
·Homograft x 3 (inclusion/cylinder/root)
·Large Ascending Aorta
·Small Aortic Root - techniques / Multiple Valve
·Ross / ·Aortic/Mitral
·Ross/Konno / ·Mitral/Tricuspid
·Modified Konno / ·Aortic/Mitral/Tricuspid
·Konno/Rastan / Valve Surgery/ Combinations
·AV repair / ·Other cardiac procedures
·Apical Aortic Conduit / ·Other non-cardiac procedures
·Ascending Aorta/Descending Aorta
·IHSS approaches
·Infective Endocarditis
·Pediatric/Congenital

Subsystem Approach to Post-operative Care

of the Adult Cardiac Surgery Point

·Hemodynamics - CO; arrhythmias; ischemia; failure; tamponade; IAB-Assist

·Respiratory - mechanical ventilation; tracheotomy; fast-track

·Hematological – Bleeding/Coagulopathy/Blood products/Conservation

·Neurological – Evaluation/ Stroke/ Seisure/Paraplegia

·Renal - Tests; acute, chronic failure

·Fluid/Electrolytes - Crystalloid/Colloid

·Infectious – prophylaxis; Immunology – Transplant

------

·Wound - sternum; leg; arm

·Vascular - PVD

·GI – prophylaxis; complications

·Nutrition – Enteral/Parenteral

·Metabolic/Diabetes - Sliding scale insulin

·Medications/Fluids/Resuscitation/ Pharmacy/ Protocols

·Clinical Pharmacology

·Nursing Aspects – protocols/ infusion systems

·ICU – design/function

Coronary Artery Disease

- Coronary Anatomy/Physiology/Pathogenesis/Pathophysiology

- Acute/Chronic Coronary Diseases/Syndromes-Incidence/Prevalence/Risk Factors/Rehabilitation

- Diagnostic testing

- Medical treatment-Drugs/Coronary Care/Rehabilitation

- Invasive testing-coronary scores/Hemodynamics

- Interventional modalities-PTCA/ Stents/ Lytic Therapy/ IVUS

- CAD scores; Syntax

- TMR/ gene therapy/ stem cell/ tissue engineering

- Heart failure-approaches (coronary/ non-coronary)

- Surgery

- History

- Studies-Historic/Recent

- Database/ QA/ Risk/ Comorbidity/ ACC-AHA Guidelines

- Indications/Timing/Techniques

- ONCAB/ OPCAB/ Minimally invasive

- Spasm/bridge/intracavitary

- Sequential/ aneurysms/ flows/ septal/ endarterectomy

- Hybrid/Total Arterial grafting

- Conduits/Leg/Arm/Other

- Left main/elderly/young/females/other operations

- Reoperation/ median sternotomy/ left chest

- Mechanical-Shock/ MR /VSD LVA/ ↓LV/Rupture

- Rehabilitation

- Cost

-Results- Early/Mid-term/ Long-term

Basic Procedures/ Techniques/ Proficiency:

Techniques

NG tube insertion

Foley bladder catheter

IV access- peripheral/ central

Chest tube insertion

Peritoneal dialysis catheter insertion

AVC fistula catheter insertion

Umbilical arterial/venous catheter placement

Broviac/ Hickman deep line placement

ET intubation

Gasrostomy/PEG/ Jejeunostomy

Equipment

Multiparameter monitor calibration, adjustments

Mechanical ventilator

CPAP

IV infusion pumps

CT suction

Temporary pacemaker

ECG, A-wire

Defibrilater

OPCAB suction devices

ECHO—TEE. TTE

IAB

Oxymetry

Somanetics monitor

Ultrasound

Proficiency

ATLS/ ACLS/PALS

Drug dosing

Rowlatt Charts

Formulas: hemodynamic/ pulmonary

ECMO placement