The Operated Heart at Autopsy (eBook)

Stuart Lair Houser (Autor)

eBook Download: PDF

2009 | 2009
XIV, 187 Seiten
Humana Press (Verlag)
978-1-60327-808-9 (ISBN)

Infos

After 17 years of private practice as a cardiovascular surgeon, my partners qu- tionedtherationalityofmydecisiontoleavetheclinicalpracticebehindandbecome acardiovascular pathologist. Infact,theirdisbeliefofmyintentiontomakethe'leap of faith' was understandable. For a surgeon, the operating room is where the action is. It is as simple as that. And when a cardiac surgeon can hold in his hand a beating heart, now off-bypass and improved by an operation just completed, satisfaction is real and profound. However, life is complex. Throughout my surgical career, questions regarding the pathogenesis of atherosclerotic cardiovascular disease arose; curiosities of va- ous phenotypes of the disease piqued my interest. I became aware of the power of investigative techniques that might address these questions. I then began to realize that my career in the operating room left me little time to address them. I needed to study the disease full time in order to contribute to my understanding of it. Ironically, my ?rst autopsy as a pathology resident was on an individual with a past history of coronary artery bypass surgery. When it came to examining the heart, the dissection, as all pathologists know, was complex. However, I found it to be straightforward and enjoyable. But I subsequently learned that my fellow re- dents and mentors did not share my intrigue and comfort in de?ning the nuances of the operated heart.

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After 17 years of private practice as a cardiovascular surgeon, my partners qu- tionedtherationalityofmydecisiontoleavetheclinicalpracticebehindandbecome acardiovascular pathologist. Infact,theirdisbeliefofmyintentiontomakethe"e;leap of faith"e; was understandable. For a surgeon, the operating room is where the action is. It is as simple as that. And when a cardiac surgeon can hold in his hand a beating heart, now off-bypass and improved by an operation just completed, satisfaction is real and profound. However, life is complex. Throughout my surgical career, questions regarding the pathogenesis of atherosclerotic cardiovascular disease arose; curiosities of va- ous phenotypes of the disease piqued my interest. I became aware of the power of investigative techniques that might address these questions. I then began to realize that my career in the operating room left me little time to address them. I needed to study the disease full time in order to contribute to my understanding of it. Ironically, my ?rst autopsy as a pathology resident was on an individual with a past history of coronary artery bypass surgery. When it came to examining the heart, the dissection, as all pathologists know, was complex. However, I found it to be straightforward and enjoyable. But I subsequently learned that my fellow re- dents and mentors did not share my intrigue and comfort in de?ning the nuances of the operated heart.

Inhalt

Preface 5
Acknowledgment 7
1 External Evidence of Open-Heart Surgery 14
Look at the Skin of the Chest Wall 15
Look at the Skin of the Extremities 16
Look for Tubes, Wires, and Lines in the Early Postoperative Period 17
Look for Evidence of Preterminal Mechical Ventricular Support 18
Look for Evidence of Acute Renal Failure 19
Miscellaneous External Findings Are Notable 19
References 20
2 Exposing the Cardiopulmonary Block 22
Adhesions Happen 22
The Chest Plate Has Information 23
Assist Devices Are Meaningful 25
Isolate the Heart with Care 25
Assess the Need for Coronary Artery Injection 27
Prepare the Aorta for Coronary Artery Injection 28
Preliminary Injection Is Instructive 29
References 32
3 The Postmortem Coronary Injection 33
Remember the Scout Film 33
Follow the Injection Protocol 34
Understand the Injection Protocol 37
A Story in Print Has Value 39
References 41
4 The Cardiac Dissection 42
The Parietal Pericardium May Be Socked In 43
Look at the External Surface of the Heart and Great Vessels 46
Take the Coronary Arteries Off the Heart 51
Stain with Tetrazolium 52
Open the Heart 53
Right Atrium 53
Right Ventricle 54
Left Atrium 54
Left Ventricle 55
Aortic Valve 58
Routine Measurements 61
References 61
5 Putting It All Together 63
Case 1: Nonpulsatile Blood Flow and the Gastrointestinal Tract 64
History 64
Procedure 64
Hospital Course 64
Autopsy Findings 64
Comment 65
Conclusions 65
Case 2: Hazard of a Re-Do Sternotomy 66
History 66
Procedure 66
Hospital Course 66
Autopsy Findings 67
Comments 67
Conclusions 68
Case 3: Cardiopulmonary Bypass in a Salvage Mode 68
History 68
Procedure 69
Hospital Course 69
Autopsy Findings 69
Comments 70
Conclusions 71
Case 4: A Problem of Heart Failure and Hardware 71
History 71
Procedure 72
Hospital Course 72
Autopsy Findings 72
Comments 72
Conclusions 73
Case 5: Prosthetic Valve Endocarditis 73
History 74
Procedure 74
Hospital Course 74
Autopsy Findings 74
Comments 75
Conclusions 75
Case 6: Aortic Root Reconstruction, Old Age, and Comorbidity 76
History 76
Procedure 76
Hospital Course 77
Autopsy Findings 77
Comments 78
Conclusions 79
Case 7: Pathology of Off-Pump Coronary Artery Bypass Surgery 79
History 79
Procedure 79
Hospital Course 80
Autopsy Findings 80
Comments 81
Conclusions 82
Case 8: Repair of Acute Aortic DissectionMaking Sense of the Findings 82
History 82
Procedure 83
Hospital Course 83
Autopsy Findings 83
Comments 84
Conclusions 85
Case 9: Technical Issues of Coronary Artery Bypass Surgery 85
History 85
Procedure 86
Hospital Course 86
Autopsy Findings 87
Comments 87
Conclusions 89
Case 10: Aortic Root Abscess and Postoperative Gastrointestinal Complications 90
History 90
Procedure 91
Hospital Course 91
Autopsy Findings 91
Comments 91
Conclusions 92
Case 11: Mitral Valve Plus Coronary Bypass Surgery on an Obese Diabetic 93
History 93
Procedure 93
Hospital Course 94
Autopsy Findings 94
Comments 94
Conclusions 95
Case 12: An Extraanatomic Approach to Treatment of Aortic Stenosis 97
History 97
Procedure 97
Hospital Course 97
Autopsy Findings 97
Comments 98
Conclusions 99
Case 13: An Acute Aortic Dissection Involving the Left Main Coronary Artery 100
History 100
Procedure 100
Hospital Course 100
Autopsy Findings 100
Comments 101
Conclusions 102
Case 14: ECMO Following Treatment of Congenital Heart Disease 103
History 103
Procedure 104
Hospital Course 104
Autopsy Findings 104
Comments 105
Conclusions 106
Case 15: Assessing Placement of a Biventricular Assist Device 107
History 107
Procedure 107
Hospital Course 107
Autopsy Findings 108
Comments 108
Conclusions 109
Case 16: Cardiac Surgery Through the Right Chest 110
History 110
Procedure 111
Hospital Course 111
Autopsy Findings 111
Comments 112
Conclusions 113
Case 17: ECMO One Day After Cardiac Surgery Through the Left Chest 114
History 114
Procedure 114
Hospital Course 114
Autopsy Findings 115
Comments 115
Conclusions 116
Case 18: Aortic Valve Replacement and Failure Coming Off Pump 117
History 117
Procedure 117
Hospital Course 117
Autopsy Findings 117
Comments 118
Conclusions 119
Case 19: Postoperative Complex Congenital Heart Disease at Autopsy 120
History 120
Procedure 120
Hospital Course 120
Autopsy Findings 121
Comments 121
Conclusions 122
Case 20: Right Ventricular Failure Following Transplantation 123
History 123
Procedure 123
Hospital Course 123
Autopsy Findings 124
Comments 124
Conclusions 125
References 126
6 Congenital Heart Disease and Surgical Footprints 133
Epsteins Anomaly 134
Single Ventricle 137
Double Outlet Right Ventricle 141
AV Canal Defect 142
Ventricular Septal Defect 143
Tetralogy of Fallot 146
Patent Foramen Ovale 151
Coronary Artery Anomaly 154
Bicuspid vs. Unicuspid Aortic Valve 157
Atrial Septal Defect 158
Patent Ductus Arteriosus 159
Transposition of the Great Vessels 161
Aortic Coarctation 162
Sinus of Valsalva Aneurysm 166
Endomyocardial Fibrosis 168
References 170
7 A Matter of Mindset 174
Exposure 174
Understanding 176
Interpretation 179
References 179
Abbreviations 179
Abbreviations 182
Glossary 179

Produkt-Details

• Erscheint lt. Verlag: 10.6.2009
• Zusatzinfo: X, 238 p. 91 illus. in color.
• Verlagsort: Totowa
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Kardiologie / Angiologie
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Pathologie
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Rechtsmedizin
• Themenwelt: Recht / Steuern ► Strafrecht ► Kriminologie
• Themenwelt: Sozialwissenschaften
• Themenwelt: Technik
• Schlagworte: Autopsy • Bypass • Congenital Heart Disease • heart • Identification
• ISBN-10: 1-60327-808-7 / 1603278087
• ISBN-13: 978-1-60327-808-9 / 9781603278089