Donaldsoncallesen4474

Liver cirrhosis is a major risk factor in patients requiring cardiac surgery. Although current evidence is limited to reports coming mostly from small case series, it is clear that the surgical risk increases with the severity of the liver disease. Hemodynamic instability caused by hyperdynamic circulation, systemic fluid retention, infection, and bleeding is frequently observed postoperatively in severely cirrhotic patients. Preoperative optimization, including correction of coagulopathy and poor nutrition, is therefore crucial for minimizing the predictive postoperative complications in those patients. Postoperative management should focus on bleeding and infection control, body fluid management, adequate nutrition, and hemodynamics, particularly hepatic circulation. Multiple studies have shown that patients who are diagnosed as Child-Pugh class B or C liver cirrhosis have a high surgical mortality rate, with most reports suggesting class C as inoperable. Recently, the model for end-stage liver disease( MELD) score has been gaining attention for its reliability in identifying patients at high risk for open heart surgery. Off-pump surgery may be beneficial in improving the surgical outcomes, but the evidence is weak and further studies are required. A thorough preoperative evaluation is thus mandatory in cirrhotic patients scheduled for cardiac surgery, with a particular attention to the risks and benefits of performing the surgery itself.The factors influencing the pulmonary function after cardiovascular surgery are decreased compliance of thorax due to sternotomy, phrenic nerve injury, wound pain and decreased blood flow after internal mammary artery harvest on coronary artery bypass grafting (CABG). Another factor is systemic inflammatory response syndrome (SIRS) associated with cardio-pulmonary bypass. So, we should take care of pulmonary function after surgery not only on the patients with pulmonary dysfunction but also on the patients with normal pulmonary function. Because the results after cardiovascular surgery for the patients with pulmonary dysfunction depends on the severity of the pulmonary function, preoperative assessment of it is important. The predictor for adverse results are chronic obstructive lung disease(COPD) itself and FEV1.0% less then 50% and so on. Even of the patients has no history of pulmonary disease, preoperative evaluation is necessary. For the patients with pulmonary dysfunction, we should consider fast-track recovery after operation, meaning early extubation, choice of less invasive surgery procedure and change of surgical procedure. Prohibition of smoking for more than 4 weeks, pre- and post-operatively pulmonary rehabilitation are also important for improve the operative results.The lower preoperative left ventricular ejection fraction( LVEF), the more postoperative death. The perioperative management for cardiovascular patients with heart failure (LVEF less then 40%) is of great importance in cardiac surgery. The failing heart is characterized by intracellular Ca2+ handling abnormalities during excitation/contraction coupling( i.e., less amount of cytosolic Ca2+ recruitment in systole and insufficient cytosolic Ca2+ extrusion in diastole), which are caused by increased reverse-mode Na+/ Ca2+ exchange activity and abnormal sarcoplasmic reticular Ca2+ channels (ryanodine receptors) and Ca2+ pumps (adenosine triphosphataseATPases). Myocardial ischemia/reperfusion (I/R) damage is characterized by intracellular acidosis followed by Ca2+ overload during I/R. The failing/hypertrophied myocardium has a low coronary vascular density, leading to low oxygen supply to the cardiomyocyte, and is vulnerable to Ca2+ load during I/R. Based on those abnormalities, hypothermic cardioplegia is recommended to suppress myocardial oxygen demand in open heart surgery for patients with heart failure(low LVEF). Optimal medical managements using adrenergic stimulators, vasodilators, antiarrhythmics, cardiac pacing, NO inhalation, or myocardial Ca2+ sensitizers under preload adjustment may be essential for hemodynamic improvement of postoperative low cardiac output syndrome. Sirtinol in vivo On a case-bycase basis, mechanical circulatory support systems should be utilized before the development of multiple organ failure.Managing patients with concurrent malignant neoplasms and cardiovascular disease is an important issue, especially with aging populations;however, the optimal treatment strategy in these patients remains controversial. We report 27 patients with simultaneous cardiac and malignant disease in our institution over the past 12 years;23 patients underwent cardiovascular surgery, 4 patients underwent cardiovascular surgery after treatment for malignant disease, and 3 patients died of malignant disease. The treatment strategy for patients with concurrent cardiac and malignant disease should be chosen according to the severity of the cardiovascular disease and the expected prognosis of the malignant disease.Severe atherosclerosis of the ascending aorta frequently causes difficulties during heart operations, hindering surgical maneuvers and potentially leading to systemic embolism. There have been several methods to solve these problems but the best way to treat patients requiring aortic valve replacement (AVR) has not been established yet. Surgical techniques for AVR in these patients include AVR under deep hypothermic circulatory arrest with or without endarterectomy of the ascending aorta or replacement of the ascending aorta. Endovascular clamping using a balloon is another approach but require manipulation of the heavily calcified aorta that may result in a certain risk for stroke. Another option to avoid the ascending aorta and cross-clamping is the apico-aortic conduit. Trans-catheter AVR( TAVR),especially trans-apical AVR, has been shown to be feasible in such patients. Large studies and longer follow-up will be required to scientifically prove the superiority of trans-apical AVR over conventional surgical strategies in patients with porcelain aorta requiring AVR.Extensive atheromatous disease of the thoracic aorta is a significant risk factor of lethal complications and remains an unsolved issue in patients undergoing cardiovascular surgery. The disease condition has been documented to be associated not only with high operative risk but also with relatively poor prognosis especially in patients with aortic replacement, due to the susceptibility to potential embolic events such as neurological deficits. To achieve favorable outcomes after surgical intervention, precise preoperative evaluation and meticulous surgical planning are important. 3-dimensional computed tomography (CT) can reveal detailed aortic lesions, graftable anastomotic sites, suitable cannulation sites, risk score related to thoracic endovascular aortic repair (TEVAR). Despite the tendency that atheromatous lesions are extensive and multiple, a selected treatment would better be targeted only for clinically significant pathologic site to minimize the risks associated with surgical intervention. In addition, realistic anticipation and subsequent preparation for potential second operation should also be planned.