**5. References**

118 Special Topics in Cardiac Surgery

related to the procedure. Both events could have a significance as risk factor for long-term

Occurrence of early postoperative conduction defects and of atrial fibrillation could also be considered as markers of advanced valvular heart disease, since some of their risk factors might be the result of protracted pressure overload on the left ventricle. Hence, these events

Non-cardiac complications could clearly be related to co-morbid conditions. These, however are not always liable to alterations. Hence, the peri- and postoperative care should be tailored for each patient. It has also become obvious that age over 80 is not a formal contraindication for AVR. Nevertheless, elderly usually have considerable co-morbidity. The EUROscore, which was developed for CABG patients overestimates the risk for hospital mortality considerably. Low ejection fraction, chronic pulmonary obstructive disease and peripheral artery disease have been identified as predictors, although (84). Pulmonary function after median sternotomy is reduced in a substantial way, probably by several mechanisms such as chest wall restriction, decreased movement of the diaphragm and

It seemed worthwhile, therefore, to explore some alternative techniques in valve surgery which could reduce the postoperative risk. These could be 1) minimal surgical access, 2)

The first alternative, minimal surgical access by ministernotomy (85-88) and anterolateral minithoracotomy (89-91) could expose the surgical field adequately. Possible indications could be obesity, chronic obstructive pulmonary disease (86) and previous chest irratiation

Some advantages have been described such as an economic benefit, improved cosmetic result, decrease in postoperative morbidity, length of stay, pain, blood loss and transfusion (86-90,92). Cross clamping time had increased, however (88). Two randomized trials have appeared, which compared minimal and conventional AVR. The first one, was very small and included 20 patients for every group (88). The second one excluded patients with obesity and pulmonary disease (85), in spite of previously mentioned indications (86). Pain and blood loss were less, but there was no less need for transfusion. No other benefits such as a decrease in renal or pulmonary complications or differences in postoperative pulmonary functions could be documented (85,88,93). Results in high risk patients were considered as excellent in a recent review, but randomized controlled trials comparing

The second approach involves the changes in extracorporeal circulation devices. The use of an extracorporeal circulation during AVR has the risks of hemodilution and of an inflammatory response, which could be reduced by an minimal extracorporeal circulation or MECC. This MECC is a closed system with a centrifugal pump, an oxygenator without a venous and cardiotomy reservoir. The patient functions as the venous reservoir (95). This reduces the contact of blood with artificial surfaces and with air. The risk for hemolysis and the need for blood transfusions also decreases (96). With MECC, there is less increase in Creactive protein, troponin I level, and better preservation of platelets and renal function. Stroke and cerebral injury were also less. The improved biocompatibility of MECC is of special advantage in high risk patients (age over 65, renal and pulmonary dysfunction). The

More recently, TAVI or transcatheter aortic valve implantation, either through an artery or through the cardiac apex has been developed as third alternative. In patients deemed unfit

minimal extracorporeal circulation and 3) transcatheter aortic valve implantation.

recurrence.

could be seen as patient related.

impairment of diffusion across the alveolar membrane (85).

or CABG with patent left internal mammary artery (91).

minimal with conventional AVR are needed (94).

use of a minimal ECC involves a learning curve, however (82).


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**5** 

*USA* 

*Vortex Medical, Inc.* 

**Application of a Novel Venous** 

**Cannula for En-Bloc Removal of** 

**Undesirable Intravascular Material** 

Albert K. Chin, Lishan Aklog, Brian J. deGuzman and Michael Glennon

Venous occlusive disease encompasses a variety of clinical entities that range the spectrum from being catastrophic and life threatening, such as massive pulmonary embolism, to disease states that may have an occult presentation, such as inferior vena cava occlusion. Other examples of veno-occlusive disease states include deep venous thrombosis and right atrial masses. When venous occlusion is characterized by an overwhelming volume of offending material, clinical therapy may be a significant challenge. This chapter examines the historical background of therapy directed at venous occlusion, and outlines a simplified

The majority of undesirable material presenting in the major venous circulation have their origins in the lower extremity veins. Deep venous thrombosis has an estimated annual incidence of over 2 million cases in the United States (Hirsh & Hoak, 1996), and accounts for approximately 600,000 hospitalizations per year (Schreiber, 2010). The genesis of venous thrombosis continues to be aptly characterized by the observations of Virchow in 1856 (Virchow, 1998, as cited in Lopez et al., 2004), who is credited with associating the triad of (1) venous stasis, (2) endothelial injury and (3) hypercoagulability with the formation of intravascular clot. The incidence of pulmonary embolism is closely tied to the occurrence of deep venous thrombosis, so much so that the complex of deep venous thrombosis and pulmonary embolism is defined by the term "venous thromboembolism". It is estimated that approximately 50% of patients with deep venous thrombosis have detectable pulmonary emboli (Hirsh, 1996). Lower extremity deep venous thrombosis in the distal vessels, e.g. calf vein thrombosis, has commonly been held to be relatively benign, and mostly asymptomatic; however, some studies have shown that propagation of calf vein clot above the popliteal level occurs in approximately 15% of patients (Lohr et al., 1991). Upon propagation to the popliteal vein, the risk of measurable pulmonary embolism increases to

Risk factors for venous thromboembolism are associated with conditions that alter elements of Virchow's triad. These include increasing age, surgery, trauma, hospital or nursing home

technique for addressing the occurrence of major undesirable intravascular material.

approximately 40% (Kakkar et al., 1969, as cited in Hirsch & Hoak, 1996).

**1. Introduction** 

**2. Etiology and incidence** 

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