Preface

**Section 2 Cardiac Surgery 219**

**VI** Contents

Popov

Chapter 13 **Cardiac Trauma 339**

**Synopsis 355**

P. A. Stawicki

**Section 3 Great-Vessel Surgery 373**

Chapter 15 **Penetrating Aortic Ulcers 375**

Arman Kilic and Ahmet Kilic

Chapter 16 **Fast – Track Total Arch Replacement 385** Tomoaki Suzuki and Tohru Asai

**Pulmonary Embolism 395**

Chapter 17 **Contemporary Surgical Management of Acute Massive**

Dawn S. Hui and P. Michael McFadden

Chapter 9 **The Basis of Management of Congenital Heart Disease 221** Krishnan Ganapathy Subramaniam and Neville Solomon

Chapter 10 **Veno-Arterial Extracorporeal Membrane Oxygenation for**

Francesco Formica and Giovanni Paolini

Chapter 12 **Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia 321**

**Ventricular Septal Defects 293**

**Refractory Cardiogenic Shock and Cardiac Arrest 273**

Michael S. Firstenberg, Kevin T. Kissling and Karen Nelson

Vladimir Shipulin, Vadim Babokin, Sergey Andreev, Vladimir Usov, Ruslan Aimanov, Anthony Bogunetsky, Roman Batalov and Sergey

Daniel Eiferman, R. Nathan Cotterman and Michael Firstenberg

Jennifer Schwartz, David E. Lindsey, Hooman Khabiri and Stanislaw

Chapter 14 **Gastrointestinal Complications in Cardiothoracic Surgery: A**

Chapter 11 **Management And Controversies of Post Myocardial Infarction**

The field of thoracic and cardiovascular surgery continues to evolve at a pace in which almost by definition any idea that is published is instantly out-of-date. Ideas are in con‐ stant evolution and new, exciting, and innovative technologies are often featured not only in mainstream Journals, but the lay-press media as well. While such progress is exciting– particularly for those at the forefront of such developments–unfortunately, it often takes years for some of these technologies to mature to the point in which they are safely and readily available to our patients. Many of these developments sometimes become restrict‐ ed to specialized centers and occasionally only available to those patients with access to referrals and resources. Furthermore, it is also unclear the extent in which such advances may actually benefit patients as some of the most significant, exciting, and expensive therapies are indicated for potentially only a small number of patients. Nevertheless, there are still numerous problems–beyond some of the basics - in which the management con‐ tinues to challenge all of those who are involved in the care of the cardiothoracic patient. As more and more of these problems require the management of multi-disciplinary Teams, the ability to speak a common language and understand complex problems be‐ comes even more important. Furthermore, as patients–for many reasons–present in vari‐ ous stages of their diseases, some very early and some very late–combined with the challenges of dealing with more complex co-morbidities, unusual problems are becoming more common and common problems are presenting in more unusual ways.

The goal of Principles and Practice of Cardiothoracic Surgery is not to be an all encom‐ passing text of an endless field, but rather to highlight some of the challenges that might be facing the Team that is often faced with dealing with the wide-spectrum of problems that can, and often are, encountered at centers throughout the world on a daily basis. Ob‐ viously topics like percutaneous valves, long-term ventricular assist devices, and thoracic organ transplantation continue to fascinate those who follow our field–but unfortunately, for many reasons, these topics, not only are constantly changing, but are rarely available outside of major medical centers and have limited availability to patients. Entire textbooks have been dedicated to these individual topics. As such, they can be of limited practical interest to the practicing surgeon who is not already at a center that performs these proce‐ dures or, conversely, who is still in training or trying to figure out how to get involved with a field that might be moving too quickly–and potentially in too many different direc‐ tions.

This text is divided into 3 sections – Thoracic Surgery, Cardiac Surgery, and Great-vessel Surgery – with not only state of the art discussions of the current literature on some of the

topics, but as importantly and emphasis on the basic"tried and true"approaches to the management of some unusual and difficult to manage problems such as the mesothelioma and post-myocardial infarction ventricular septal defects. In addition, chapters on such topics ranging from extra-corporeal membrane oxygenation and surgery for massive acute pulmonary embolism are also presented as potentially valuable references for those clini‐ cians who rarely encounter such problems, but when they do, immediate access to a standard reference with a recipe for success is critical in the setting of an acutely lifethreatening problem.

tients, sometimes at their time of greatest need and uncertainty. Basically, the hope is that

**Michael S. Firstenberg, MD FACC** Department of Surgery (Cardiothoracic)

Preface IX

Northeast Ohio Medical University, USA

Summa Health Care System – Akron City Hospital Assistant Professor of Surgery and Integrative Medicine

this text will be a starting point for a life-long journey.

In addition, chapters that focus specifically on the peri-operative management of these pa‐ tients and their complex problems are also included. The field of anesthesia for thoracic surgery is constantly changing as clinicians continue to strive to make the task of single lung ventilation and even general anesthesia for pulmonary resections safer. The insights from this chapter are of value to surgeon and anesthesiologist alike as there are few areas in medicine in which it is so critical that physicians from different specialties be able to communicate in a common language. Similarly, the chapters that discuss the management of complications after thoracic procedures and potentially catastrophic gastrointestinal problems after cardiac surgery are also included to serve as a reference point for dealing with these issues when their arise.

Of course, no text on cardiothoracic surgery would be complete without a foundation in the complex anatomy and the embryologic development of the heart to assist in putting any procedure into a proper context. A fundamental understanding of anatomy and em‐ bryology is critical to our field and one can never be too educated on this topic–in fact, I am sure most practicing physicians could always benefit from further education in this area.

The international and diverse nature of the authors allows the reader to also avoid some of the inherent regional bias that comes from texts in which the opinions and experiences of a single center are discussed. While such experiences are of considerable value and are considered sometimes"state of the art", there are concerns about whether some of the techniques and outcomes can be translated into common and daily practice–and in the spectrum of environments that might be represented by the anticipated audience.

The open-access model of this text also addresses some of the practice concerns to provid‐ ing knowledge to those who need it most but who are typically the least likely to have access to it (typically due to financial constraints of scientific publishing). While physical copies of this text are available, the real benefit stems for the ability to access and down‐ load individual chapters on an as-needed basis from anywhere in the world and without charge. The benefits of this model of distribution of medical knowledge will only continue to grow in the future as more and more medial, in general, is distributed electronically and availability is provided anywhere, anytime, for anyone–and without cost.

Principles and Practice of Cardiothoracic Surgery will only be one of countless texts on the topic. The information, like all texts, will reflect a"snap-shot"of the understanding of the topics presented at a point in time. While it would be foolish of any author or editor to claim their work is the definitive, complete, and final word on any topic–the true goal of this work is to provide a foundation of knowledge of common, unusual, and intriguing problems that will hopefully spark further curiosity on the various topics, serve as a new baseline for further growth in the field, and most importantly–help clinicians to help pa‐ tients, sometimes at their time of greatest need and uncertainty. Basically, the hope is that this text will be a starting point for a life-long journey.

topics, but as importantly and emphasis on the basic"tried and true"approaches to the management of some unusual and difficult to manage problems such as the mesothelioma and post-myocardial infarction ventricular septal defects. In addition, chapters on such topics ranging from extra-corporeal membrane oxygenation and surgery for massive acute pulmonary embolism are also presented as potentially valuable references for those clini‐ cians who rarely encounter such problems, but when they do, immediate access to a standard reference with a recipe for success is critical in the setting of an acutely life-

In addition, chapters that focus specifically on the peri-operative management of these pa‐ tients and their complex problems are also included. The field of anesthesia for thoracic surgery is constantly changing as clinicians continue to strive to make the task of single lung ventilation and even general anesthesia for pulmonary resections safer. The insights from this chapter are of value to surgeon and anesthesiologist alike as there are few areas in medicine in which it is so critical that physicians from different specialties be able to communicate in a common language. Similarly, the chapters that discuss the management of complications after thoracic procedures and potentially catastrophic gastrointestinal problems after cardiac surgery are also included to serve as a reference point for dealing

Of course, no text on cardiothoracic surgery would be complete without a foundation in the complex anatomy and the embryologic development of the heart to assist in putting any procedure into a proper context. A fundamental understanding of anatomy and em‐ bryology is critical to our field and one can never be too educated on this topic–in fact, I am sure most practicing physicians could always benefit from further education in this

The international and diverse nature of the authors allows the reader to also avoid some of the inherent regional bias that comes from texts in which the opinions and experiences of a single center are discussed. While such experiences are of considerable value and are considered sometimes"state of the art", there are concerns about whether some of the techniques and outcomes can be translated into common and daily practice–and in the

The open-access model of this text also addresses some of the practice concerns to provid‐ ing knowledge to those who need it most but who are typically the least likely to have access to it (typically due to financial constraints of scientific publishing). While physical copies of this text are available, the real benefit stems for the ability to access and down‐ load individual chapters on an as-needed basis from anywhere in the world and without charge. The benefits of this model of distribution of medical knowledge will only continue to grow in the future as more and more medial, in general, is distributed electronically

Principles and Practice of Cardiothoracic Surgery will only be one of countless texts on the topic. The information, like all texts, will reflect a"snap-shot"of the understanding of the topics presented at a point in time. While it would be foolish of any author or editor to claim their work is the definitive, complete, and final word on any topic–the true goal of this work is to provide a foundation of knowledge of common, unusual, and intriguing problems that will hopefully spark further curiosity on the various topics, serve as a new baseline for further growth in the field, and most importantly–help clinicians to help pa‐

spectrum of environments that might be represented by the anticipated audience.

and availability is provided anywhere, anytime, for anyone–and without cost.

threatening problem.

VIII Preface

area.

with these issues when their arise.

#### **Michael S. Firstenberg, MD FACC**

Department of Surgery (Cardiothoracic) Summa Health Care System – Akron City Hospital Assistant Professor of Surgery and Integrative Medicine Northeast Ohio Medical University, USA

**Section 1**

**Thoracic Surgery**

**Section 1**

**Thoracic Surgery**

**Chapter 1**

**Anesthesia for Thoracic Surgical Procedures**

As thoracic surgery evolved, anesthesia evolved in parallel, allowing even the most compli‐ cated surgical procedures to be performed relatively safely. This co-evolution mirrors the close association of the thoracic surgeon and anesthesiologist when caring for their patients. This unique association is predicated on the nature of thoracic procedures, where the surgeon and anesthesiologist share a "thoracic workspace" - the surgeon operating on vital thoracic structures and the anesthesiologist managing ventilation, oxygenation, and hemodynamics. Because of this close partnering, it is valuable for thoracic surgeons to be familiar with

Thoracic Surgery poses unique challenges to the anesthesiologist, including surgery in the lateral decubitus position, an open thorax, manipulation of thoracic organs, potential for major bleeding, and, unique among all potential surgery scenarios, the need for lung isolation.

Successful lung isolation (one-lung ventilation, OLV) requires the management of oxygena‐ tion, ventilation, and pulmonary blood flow. Remarkably, OLV decreases total minute ventilation minimally. In fact, it has been shown that the non-isolated lung receives close to the same minute ventilation as ventilation to two lungs. The rate of CO2 elimination undergoes minimal changes because CO2 is readily diffusible and has no plateau in its dissociation curve.

> © 2013 Tsai et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

January Tsai, Teresa Moon, Shital Vachhani,

Additional information is available at the end of the chapter

anesthetic considerations exclusive to their patients.

**2.1. Physiologic effects of lung isolation**

**2. Considerations for One-Lung Ventilation (OLV)**

Javier Lasala, Peter H Norman and

Ronaldo Purugganan

http://dx.doi.org/10.5772/56104

**1. Introduction**
