At 10 years, and beyond, the pericardial valve did function well in the aortic position, as reported by various authors., [ 35 ] [ 36 ] [ 37 ] [ 38 ]  Several pericardial valves were explanted from the aortic position at 16, 17 and 18 years following implantation, and a few valves between 21 and 23 years. [ 35 ] [ 38 ]  Pericardial valves in the mitral position fared less well beyond 5 – 6 years, as reported in some series, but not in others. Ravichandran [ 35 ]  reported a series of 34 patients (with 41 valves) who were re-operated upon for removal of failed Ionescu-Shiley pericardial valves. The failures occurred at a mean duration since 'implantation' of 11.3 years (mean range 3–17 years). There were 30 mitral and 11 aortic valves involved, and the majority were moderately or heavily calcified. Watanabe  [ 39 ]  describes a case of an Ionescu-Shiley bioprosthesis which functioned 24years in the mitral position of a patient.


The known modes of tissue valve failure are: tearing of the pericardium, calcification of the valve and, exceptionally, fibrosis of the cusps. Tears represent approximately 25% and calcification 75% of primary failure. In some cases both pathologies could be encountered in the same valve. This proportion varies considerably and could be seen reversed in some series of patients.


The causes for pericardial tears were described in detail [ 34 ] [ 37 ]  and can be summarised as an abrasive mechanism produced by the rubbing of the pericardium over the Dacron-covered margin of the supporting stent. Such tears progress slowly until a part of one of the cusps becomes flail and the amount of regurgitation increases. This explains the fact that there is no sudden catastrophic failure with the pericardial valve, except when the initial, obvious clinical signs and symptoms of incipient malfunction have been missed or disregarded by the treating physician or the patient. There may be, in a minority of cases, some slightly different mechanisms of pericardial damage at points of three-dimensional flexure or perforation caused by the excessively long ends of sutures used in aortic valve replacement.


Several techniques have been used in order to reduce or abolish 'abrasion', as will be described later. [ 37 ]  Within the limitation of the intrinsic durability of the chemically treated bovine pericardium, various modifications, physical and chemical, could be employed to eliminate this type of failure and considerably extend the functioning life of this valve.


Valve calcification is a local representation of a general biologic phenomenon which occurs under specific conditions in various parts of the body, especially in younger individuals. Valve calcification is known to have taken place in all types of tissue valves. Because some important details are not given in the reported series (age of patients, timing of occurrence, position of the valve, etc.) it is difficult to form a clear-cut conclusion in all situations.


One report on a large series of patients followed for six years, presented at a symposium in 1985, [ 27 ]  gave clear and complete information regarding the relationship between valve calcification and the age of the patients at the time of valve implantation. The authors showed that in the groups of patients aged between 10 and 59 years, the incidence of valve calcification ranged from 31.8% (in the age group of 10 to 20 years) to 1.8% (in the group aged 50 to 59 years) to reach zero calcification in patients older than 70 years. Similar conclusions about the relationship between age and valve related complications were published about porcine valves. [ 40 ] [ 41 ]  The clear demonstration of this inverse relationship between the age of the patient and the rate of valve calcification 'sounded an alarm bell' and started to change the way in which tissue valves (porcine aortic and bovine pericardium) should be used in the future, and indicated the direction in which potential future research should be concentrated in order to make tissue valves universally acceptable by young and old patients without problems. At this moment in time,(2011), tissue valves are almost exclusively used in patients older than 65 years because in old age the process of calcification is considerably slowed down and also because the life of the valves may outlast the life of those patients who reach a 'respectable' age.


Several attempts have been made in order to abolish or at least to delay the occurrence of calcification. Two chemical processes were put forward: the T6 by Hancock Laboratory and the PV2 by Edwards Laboratory. The two chemical interventions had been tested in animals and in humans with unconvincing results. Subcutaneous implants, in rats, of cusps of porcine valves and strips of pericardium showed some positive results. [ 42 ]  However, care should be exercised in extrapolating such data obtained from subcutaneous implants to intracardiac location and function of valves in humans.


Jones  [ 43 ]  and associates using the well known sheep model, which is a rapidly, universally and highly calcifying model, implanted porcine and pericardial valves either 'standard' or pre-treated with the Hancock T6 or the Edwards PV2 processes. The results showed that these processes mitigated the calcification of porcine valves but did not have any effect on the pericardial valves. Gallo [ 44 ]  conducted similar experiments using the same model as Jones and Ferrans and implanted  Hancock porcine valves , with and without the T6 treatment, in the mitral and tricuspid positions of sheep. He found no significant difference in the amount of cusp calcification between the standard and the T6 treated valves, whether in the mitral or in the tricuspid position.


Although very little is known about the exact causes of this extremely complex process of calcification, attempts are made to treat it.


Macro and microscopic pathology studies of failed porcine bioprostheses by Schoen and Cohn [ 45 ]  showed in detail the process of tissue degeneration in valves with tears, calcification, or both. They consider that patients with porcine aortic bioprosthetic valves follow a clinically satisfactory course for around five years after operation. Late deterioration of these valves frequently necessitates re-operation. They estimate the rate of failure at approximately 15 to 25%, 7 to 10 years after valve implantation. Gallo and his associates [ 41 ]  describe in detail the rate of occurrence and timing of primary tissue failure with the Hancock porcine valve, and show a similar percentage of failures. The actuarial freedom from valve failure in the mitral position at 10 years is 69%, and in the aortic position only 53%. The rate of tissue valve failure accelerated from the third post-operative year in the mitral position, and from the fifth year in the aortic position with a precipitous fall during the 8th and 9th years of follow-up. They believe that the patient can be told that he or she has a 30% chance of requiring re-operation because of the porcine valve degeneration within the next 10 years. This general calculation does not take into account the other causes of valve 'problems' which may lead to re-operation or some other morbidity during that period of time. Goffin [ 46 ]  showed in a comparative histological study of explanted porcine and pericardial valves that the microscopic pathologic changes were similar in these two types of tissue. Grabenwoger [ 47 ]  found similar pathologic changes in the failed Sorin Pericarbon pericardial valve.


These long-term studies showed that both the tissue of pig valves and that of calf pericardium behave in a similar manner when used for valve replacement in humans. In a simplified way, the main difference between these two types of valves is the haemodynamic superiority of the pericardial valve and its smaller risk for embolisation. But the overwhelming advantage of the pericardial valve remains the fact that, being a man-made device, it lends itself to a variety of changes in order to improve its performance.


In most published reports about tissue heart valve replacement, there are differences in the presentation of data and of the results in all aspects of a particular topic between the various publications. In almost all chapters of valve function, with the exception of haemodynamic and hydraulic measurements - which are scientifically obtained and mathematically expressed - there are differences from author to author. Why in the hands of one surgeon, the same type of tissue valve fails in one patient at 24 months, and in another one it lasts 243 months? Microscopic studies performed on porcine and pericardial valves, explanted because of failure between 12 months and 6 years, all showed gross histological changes in the structure of tissue. [ 45 ]  In view of these changes in those valves, how did some of the porcine and pericardial valves continue to function well beyond 10 years? Why did the rate of occurrence of bacterial endocarditis differ from one hospital to another, and the embolic rate vary from surgeon to surgeon?


An overview of the publications on this topic may lead to the formulation of some tentative answers. There are, generally speaking, several potential factors which may affect variously the durability of tissue valves, and which may explain the discrepancy among published results. Carlos Duran [ 48 ]  summarised some of them in the following way:


Great damage can be inflicted on a bioprosthesis at the time of its implantation. One of the not so rare causes is allowing the cusps of the valve to become dry – to look like parchment - during the time of placement of sutures. Some errors occurred exceptionally: The plastic identification tag remained attached to the valve and became stuck to the left ventricle wall; the sutures meant to secure the introducer were not removed and all three cusps of a valve were limited in their movement; entangling sutures around the stent struts, sometimes around two struts: (one of the incidents was published under the title of 'Fatal bioprosthetic regurgitation immediately after mitral and tricuspid valve replacement with Ionescu-Shiley bioprosthesis'). [ 50 ]


During 1986, Shiley made a substantial and original modification to the pericardial valve. The stent was redesigned. It was made of two wafer-thin, unequal, flexible  Delrin  components: an outside, standard-shaped frame and an inner, smaller structure. The pericardial cusps were mounted inside the outer frame and were kept in position by the inner frame which is smaller and much thinner than the outer one. Through this arrangement, the lower parts of the pericardial cusps exit from the supporting frame at its bottom, and therefore the pericardium does not bend over the upper margin of the stent, eliminating the possibility of abrasion during the closure phase of the valve. As it was learned from clinical and from in-vitro studies, abrasion of the pericardium was a cause of valve failure when the tissue was attached on the outside of the stent. [ 34 ] [ 37 ]  The in-vitro testing of this modified pericardial valve showed almost identical hydrodynamic results when compared with the existing pericardial valve. [ 51 ]  Accelerated life-testing showed that failure of this new valve occurred some 3 to 4 times later than that of existing valves. When valve failure occurred, it was not due to abrasion but through progressive fraying of the pericardium. Encouraged by these results, Shiley decided to start manufacturing this modified, improved valve called the 'Ionescu-Shiley Pericardial Optimograft'. [ 52 ]


At about that time, grave problems were encountered by Shiley with the increasing number of sudden failure of the Bjork-Shiley mechanical disc valve. [ 53 ]   Pfizer  laboratories, the drug manufacturer and owner of Shiley, stopped all manufacturing activities of Shiley Laboratory, with a view to liquidate the company. Consequently, not only was the Bjork-Shiley valve (the culprit) affected by this action, but all other products – valves, oxygenators, catheters, etc. - went out of production.


It was said (by Mr Larry Wettlaufer: Vice-President at Shiley Inc. 1987) that Ionescu did not want to go to another valve manufacturer with his 'Optimograft' and that he preferred his Himalayan climbing expeditions instead.


A careful appraisal of the results and the evolution of the two types of tissue valves created and used during the past four decades brings into focus the similarities but mainly the discrepancies which set them apart as structures and as functioning valves. The porcine valve was subjected to several modifications which reached the limits imposed by the fixed geometry of the pig's aortic valve.


The pericardial valve, the embodiment of the concept of 'man-made' devices, lends itself to an infinite permutation of changes of shape and physico-chemical interventions in order to improve its function, and indeed this is what happened. Almost 10 years after the creation, by Ionescu, of the pericardial valve, the concept behind it attracted several specialised laboratories to study this valve, to modify and improve it and bring it anew in the clinical field of usage, under different shapes and names, but always following the same general concept: glutaraldehyde-treated bovine pericardium mounted on a flexible frame as a three-cusp valve.


Building the second generation of pericardial valves was possible, first of all, because there existed a first generation. The originality of the concept, the successes and failures, the flaws and positive aspects of the original pericardial valve and the experience accumulated with its use over the first 10 to 15 years created the incentive and showed the way for changes, modifications and potential improvements in building the valves of a second generation.


Of the several pericardial valves built since 1980, some have been abandoned early and only three have stood the test of time. These three modified and improved pericardial valves were made respectively by Mitral Medical Inc. (now part of the Sorin group), Edwards Laboratories (now Edwards Lifesciences) [ 54 ]  and the Sorin Group. [ 55 ]  All three laboratories have devised different techniques of valve construction with the aim of reducing or abolishing the risk of tissue abrasion. The specialists at Mitral Medical Inc. retained the technique of mounting the pericardium outside the stent as in the original Ionescu valve, but found other ways of reducing abrasion. The Edwards engineers used an ingenious way of mounting the pericardium inside the stent albeit with a minimum loss of useful opening flow area. The Sorin technicians devised yet another way of mounting the pericardium in a double layer so as to have the stent margin padded with a pericardial sheet (similar to one of Shiley's modifications [ 37 ] ).


The Edwards valve became available in 1980. The device made in the configuration for mitral replacement had to be withdrawn, after implantation in a small number of patients, because of excessive flexibility of the stent causing mitral incompetence. A new redesigned version of this valve was reintroduced in 1984. [ 56 ]  The Mitroflow valve, as first manufactured by Mitral Medical in 1982, had to be redesigned because it showed a failure mode similar to the first generation of pericardial valves. Since 1991 a modified version of this valve was introduced and has been used in a large number of patients. [ 56 ]  The additional changes made in the configuration of these two valves demonstrate, once again, the advantage of the versatility of the 'man-made concept' of the pericardial valve.


The haemodynamic characteristics of these 3 types of valve [ 57 ] [ 58 ]  are similar to the excellent results found with the original Ionescu-Shiley valve as described by Tandon's group. [ 3 ]


The minor differences in gradients and in calculated surface area do not show a significant difference at clinical level. The adjacent image portrays the opening characteristics of 4 pericardial valves - Hancock (no longer available), Mitroflow, Edwards and Shiley. The cusps of these valves open synchronously up to a very large surface area only minimally different from one valve to another. All 4 valves were manufactured for clinical use and all were 25mm in diameter. The valves were photographed under identical conditions in the mitral side of a 'pulse duplicator' and the flow rates, at peak of diastole were: for each frame, from left to right: 0, 100, 200, 300, and 400 ml/s.


Regarding infective endocarditis, embolic complications and bleeding due to anticoagulant treatment, there is only scant data in the publications analysed for this article. It is presumed, and not without good reason, that the main emphasis was placed by the authors on structural valve deterioration (SVD). It can also be considered logical that these three types of pericardial valves, having a similar structure and dynamic function as the original Ionescu pericardial valve, such complications, 'grosso modo', would have occurred at about the same rate as reported by the users of the Ionescu valve as already reported in this article.


The scientific publications on these three, second generation pericardial valves are not only few in number but they lack some of the necessary, standardised data for a complete, clear and fair evaluation of the results. In order to avoid generalities and averages, the data reporting SVD is presented in the form of tables.


Table IV. Mitroflow Pericardial Valve


A = Aortic; M = Mitral; D = Mitral and Aortic, T = Tricuspid, SVD = Structural Valve Deterioration.


The lack of standardised data presented in the various publications makes interpretation difficult. The discrepancy of the actuarially presented results between the various publications is evident.


Table V. Edwards Pericardial Valve


A= Aortic; M= Mitral; T = Tricuspid; SVD = Structural Valve Deterioration; SBE = Subacute Bacterial Endocarditis


The inverse relationship between the age of the patients and the rate of SVD is obvious in most reports.


There are very significant differences among the various publications concerning the figures of actuarial freedom from SVD. Published data from Dr. Carpentier on structural dysfunction of the valve which carries his name would have been useful, but a search through the relevant medical literature, has not revealed any such publications.


Table VI. Sorin Pericarbon Pericardial Valve


A =Aortic; M = Mitral; D = Mitral and Aortic; T = Tricuspid; P = Pulmonary; SVD = Structural Valve Deterioration.


(i)  This figure should be interpreted with caution because the study was of only 39 patients with mitral replacement and only 2 patients were at risk at 10 years. The patients' ages were not supplied in detail.


(ii)  This study describes only the pathology of failed valves in 9 patients (out of a series of 144), 51 –79 years old (mean 69) followed-up for 6 – 8 years. The description of clinical use and results of the 144 patients who received Sorin Pericarbon Pericardial Valves would have been of great interest, but a search through the relevant medical literature has not found any such publication from the surgical team.


There are very few published reports containing sufficient data in order to be useful. One can only note, without much comment, the gross difference between the SVD shown in these three tables.


A scientific comparison among these 3 second generation valves, and between them and the Ionescu-Shiley valves is practically impossible. The number of patients in the published series varies considerably.


For the Shiley valves there had been an almost equal distribution of mitral and aortic replacements. For the new generation valves, the ratio was about 5:1 in favour of the aortic valve. The much smaller number of mitral valve replacements is due in part to the reduction of mitral valve disease in the general population and, at the same time, because of the increase in the number of patients with degenerative aortic valve disease in a progressively aging population. Another reason appears to be the perception of some surgeons that pericardial valves in the mitral position are more susceptible to SVD, than in the aortic position. The time-frame of their usage also varies. Surgical techniques and experience in general have evolved over the past 40 years. The lessons from the past might have borne fruit. The experience with the Shiley valves shows that 75-80% of valve failure was due to calcification and only 20-25% failed because of abrasion and possibly because of design flaws. The knowledge about the type of valve failure - abrasion and, especially, calcification - have placed tissue valves in a new perspective and gave the surgeons a different outlook. The greatest achievement after the first 10–15 years of usage of the first pericardial valves, was the realisation of the inverse relationship between patient age and valve calcification. This was known before, from the porcine valve experience, but it has not received sufficient emphasis until the use of pericardial valves.


The data presented in the above three tables allow one to draw some conclusions based on existing factual results but also on overall general impressions.


The second generation of pericardial valves have only occasionally failed due to tissue abrasion, although tears have still occurred.


Calcification of the tissue occurred later in elderly patients because mineralisation develops later and advances slower in old age.


These modified valves have been used preferentially, if not exclusively, in older patients and in a considerably larger proportion for aortic valve replacement rather than in the mitral position where the risk of SVD was, and remains, higher. These elements distort significantly all chance of a comparison with the series of Shiley valves.


During the 1970s and 80s, Shiley pericardial valves had been used in patients of all ages, and particularly in patients under the age of 65 years. During the 1990s and into the following decade, the mean age of patients receiving the second generation of pericardial valves varied between 67.2 and 72 years, a very significant difference in age.


The technical improvements made in the second generation of valves has apparently reduced the risk of cusp abrasion. This advantage was not fully exploited because these valves were used only in a small proportion in young patients who would have benefited more from this technical advancement. Despite claims that all 3 types of second generation valves were treated with 'so-called' anticalcification processes, the clinical results have not shown any benefit from such chemical treatment. The only reason for the reduced rate of calcification - and therefore of structural valve deterioration - in patients receiving these second generation valves was the advanced age of the patients who received them. The age of the patients was shifted from a mean of around 50 years with Shiley valves, to a mean of between 67 and 72 years with the second generation valves.


It is regretable that pericardial valves, which are known to carry a very low risk of embolisation, were not used more often in the mitral position where the need and benefit would have been greater.


However, in general, the second generation pericardial valves represent a progress in the armoury of devices for the treatment of heart valve disease. If the process of valve calcification could be controlled, these pericardial valves would become the panacea for patients in need of heart valve replacement.


In general, it is known that success depends on knowing how long it will take to succeed. For the time being, one has to accept that most of the aspects of the present are accessible only to Prophesy, about the future, the understanding of the phenomenon 'calcification' and its prevention, may lay somewhere beyond the horizon.


A short history of the introduction in clinical use of valves made of animal tissue for heart valve replacement in humans allows us to appreciate the evolution of this chapter of cardiac surgery and to imagine future potential developments in this field.


1965  Duran and Gunning in Oxford, England, published their experimental work of implanting porcine aortic valves in dogs and the previous year they had already performed the first successful porcine aortic valve replacement in one human patient. [ 73 ] [ 74 ]


1965  Binet and associates in Paris, France, began the use of porcine aortic valves for aortic valve replacement in humans. [ 75 ]


1967  Ionescu and associates in Leeds, England, used for the first time porcine aortic valves mounted on an original valve support for mitral valve replacement in humans. [ 76 ]


1969  Hancock Laboratory in Irvine, California introduces the first commercially available porcine aortic valve for use in patients. [ 77 ]


1969  Carpentier and associates in Paris, France, advocate the use of glutaraldehyde for chemical treatment of porcine aortic valves. [ 78 ]


1971  Ionescu and others in Leeds, England, creates the first bovine pericardial heart valve and begins its implantation in humans. [ 79 ]


1980  Since the early 1980s several modified pericardial valves have been built. Three of them with improved characteristics are being successfully used, as shown in this article.


The two important creative stages in tissue heart valves (from 1964 to 1971) took place in a short space of seven years and that since 1971 when the concept of 'man-made pericardial valves' was created, no other significant invention has occurred in this field except the use of bovine pericardium in the construction of transcatheter valves for aortic valve replacement.


The porcine valve was used successfully under several names, made by different laboratories, with various modifications and slight improvements without becoming essentially different from the original, native, pig's valve shape. However, the porcine valve, although far from perfect, was very useful in helping a large number of patients over many years.


The bovine pericardial valve had been created in 1971 and over the following 4 decades, with various modifications and improvements made by different
, it became, due to its superior overall qualities, the tissue valve of choice for the great majority of surgical groups around the world.


The pericardial valve is not simply another valve, it is the embodiment of a concept of tissue valve construction. At present the bovine pericardium is being used, tomorrow perchance an even better material will be found.


In this respect, Ionescu made, in one of his early papers, a significant and rather prophetic statement:


The physico-chemical and biological properties of the natural porcine aortic valve have been profoundly altered by various interventions in order to adapt it for therapeutic means. In this way, the porcine valve has lost all its primordial characteristics except its shape which remains unchanged and unchangeable. The pericardial valve, on the other hand, has been conceived as an entirely 'man-made' valve and therefore its shape and general characteristics can be altered through a multitude of interventions in order to optimise its function [ 80 ]


Adhuc sub judice lis est:  Quintus Horatius Flaccus (68-8 BC)  [ 81 ]


Contrary to what is mentioned in this article, a short publication, co-authored by A. Carpentier, was found. [ 82 ]  It presents a small series of 61 patients who received isolated aortic valve replacement with Carpentier-Edwards pericardial valves. The authors state that at 6 years of follow-up 'there have been no cases of  periprosthetic  leak, no cardiac insufficiency and no thromboembolism' This short article does not contain any other 'significant' information.


In a recent publication Dr. Denton A Cooley, who used a very large number of Ionescu-Shiley Pericardial Xenografts, mentioned the following: I still have surviving patients with functioning Bjork-Shiley and Ionescu-Shiley valves, some of which were implanted 30 or more years ago. [ 83 ]


There are now more than 40 years since Doctor Ionescu introduced, for the first time, the glutaraldehyde treated bovine pericardium in clinical use in the form of a three cusp heart valve (The Ionescu-Shiley Pericardial Xenograft). It is of interest to know that now, 40 years later, the bovine pericardium is still used in three medical/surgical devices.


1. The second generation of Pericardial Xenografts as described in the above article are used in large numbers.


2. For the manufacture of "Transcatheter Aortic Valve Implantation" devices which are used in progressively larger numbers of selected patients, especially in Europe.


3. For the manufacturing of cardiac ventricular chambers in an experimental artificial heart under testing in a French laboratory.


A  pericardial window  is a  cardiac surgical  procedure to create a  fistula  – or "window" – from the  pericardial space  to the  pleural cavity . [ 1 ]  The purpose of the window is to allow a  pericardial effusion  or  cardiac tamponade  to drain from the space surrounding the  heart  into the  chest cavity . [ 2 ]


Pericardial window may be used to treat  pericardial effusion  and  cardiac tamponade . [ 2 ] [ 3 ]  It is the most common procedure to treat pericardial effusion, particularly if caused by  cancer . [ 4 ]  Untreated, these can lead to  death . The pericardial window decreases the incidence of postoperative pericardial tamponade and new-onset  atrial fibrillation  after  open-heart surgery . [ 5 ]


Creation of a pericardial window is a major  surgical procedure . [ 6 ]  To remove  pericardial fluid , other more minor techniques should be considered first, such as  pericardiocentesis . [ 4 ]


Pericardial window is usually performed under  general anaesthetic  by a  cardiac surgeon . They may make an open  surgical incision  of up to 10  cm . [ 6 ]  This is usually located below the  xiphoid process  of the  sternum  (sub-xiphoid). [ 4 ]  Alternatively, access may be gained  thoracoscopically  with a smaller surgical incision. [ 3 ] [ 7 ]  A small hole of between 1 cm and 2 cm is cut in the  pericardium , which is the membrane that surrounds the  heart . [ 6 ]  This allows for any  pericardial fluid  and other fluid to escape from the pericardium. [ 6 ]


Pericardial window was first performed by  Baron   Dominique Jean Larrey  in  1829 . [ 6 ] [ 8 ]


Pericardial windows are commonly used in  veterinary medicine  to treat pericardial effusion. [ 7 ]  Whereas a sub-xiphoid skin incision is preferred in humans, a left para-xiphoid skin incision is preferred in  cats . [ 9 ]


Pericardiectomy  is the surgical removal of part or most of the  pericardium . [ 1 ] [ 2 ]  This operation is most commonly used to relieve  constrictive pericarditis , or to remove a pericardium that is  calcified  and  fibrous . [ 2 ]  It may also be used for severe or recurrent cases of  pericardial effusion . [ 3 ]  Post-operative outcomes and mortality are significantly impacted by the disease it is used to treat. [ 4 ] [ 5 ]


Pericardiectomy is used to treat  constrictive pericarditis , which is caused by a variety of conditions. [ 2 ] [ 3 ]  It is also used to treat recurring cases of  pericardial effusion . [ 3 ] [ 4 ]


Pericardiectomy should not be used if more minor procedures are more appropriate, such as a  pericardial window . [ 6 ]  Pericardiectomy may not be appropriate for patients who already have a poor prognosis, as its medical benefit is reduced. This is because pericardiectomy has a higher rate of  complications  and a higher  mortality . [ 6 ]  More conservative treatment may use  diuretics ,  digoxin ,  steroids ,  NSAIDs , or  antibiotics  to change  cardiovascular physiology  without treating the underlying pathology, which is appropriate for those not suitable for major surgery. [ 7 ]  Some patients may undergo conservative treatment for a number of months before pericardiectomy is considered truly necessary. [ 7 ]


Pericardiectomy can cause a number of cardiac issues, such as  arrhythmia , low cardiac output syndrome, and  myocardial infarction  (in rare cases). [ 2 ]  There is some risk of damage to the  pleural cavities  around the  lungs , which can lead to  pneumonia , or  pleural effusion . [ 2 ]  It also presents typical  surgical risks , such as  infection ,  anaesthesia  complications,  blood clots , and  bleeding . [ 2 ] [ 3 ]  There is a low risk of  haemorrhage  if the heart is  perforated  whilst removing the pericardium. [ 3 ]


Outcomes after surgery depend significantly on the underlying cause of illness, and the function of the  kidneys ,  left ventricle , and  pulmonary arteries . [ 5 ]  Recovery from pericardial effusion treated with pericardiectomy is typically very good. However, its use for treating constrictive pericarditis has a fairly high  mortality rate , initially between 5% and 15%. [ 3 ] [ 4 ]  The 5-year survival rate is around 80%. [ 3 ]  The most common complication after surgery is reduced  cardiac output , which occurs in between 14% and 28% of patients. [ 4 ]


Pericardiectomy takes place by removing the infected, fibrosed, or otherwise damaged pericardium. The procedure begins when the  surgeon  makes an incision in the skin over the  breastbone  and divides the breastbone to expose the pericardium, known as a  median sternotomy . [ 3 ] [ 6 ]  Alternatively, a larger incision known as a  thoracotomy  may be used. [ 6 ]  During the surgery, the surgeon will hold the pericardium, cut the top of this fibrous covering of the  heart , drop it into the specimen bag, and re-cover the heart. The breastbone is then wired back together and the incision is closed, completing the procedure. When the portion of pericardium lying between the two  phrenic nerves  is excised, it is called total pericardiectomy. In cases where total pericardiectomy is not possible, subtotal pericardiectomy is performed or, in extreme cases, a cruciate incision on the pericardium is performed. [ citation needed ]


Heart function often recovers very quickly after pericardiectomy is performed, [ 8 ]  although the surgery itself can cause reduced cardiac output in the short term. [ 4 ]  After surgery, many patients will have a  chest drain  to remove  pericardial fluid . [ 2 ]  Hospital recovery takes several days, with  surgical suture  removed after a week. [ 2 ]


After pericardiectomy, the heart takes on a more rounded shape due to the lack of stretch with the  diaphragm . [ 9 ]  This does not appear to cause any cardiac issues, but may be detected with  echocardiography . [ 9 ]


Postperfusion syndrome , also known as " pumphead ", is a constellation of  neurocognitive  impairments attributed to  cardiopulmonary bypass  (CPB) during  cardiac surgery .  Symptoms of postperfusion syndrome are subtle and include defects associated with attention, concentration, short-term memory, fine motor function, and speed of mental and motor responses. [ 1 ]   Studies have shown a high incidence of neurocognitive deficit soon after surgery, but the deficits are often transient with no permanent neurological impairment. [ 1 ] [ 2 ]


A study by Newman et al. at  Duke University Medical Center  showed an increased incidence of cognitive decline after  coronary artery bypass surgery  (CABG), both immediately (53 percent at discharge from  hospital ) and over time (36 percent six weeks, 24 percent at six months, and 42 percent at five years). [ 3 ]   This study shows an association of neurocognitive decline with CABG, but does not show  causation ; the study lacks a  control group  and is considered  level II-3 evidence . Also, the statistical calculation of cognitive decline has been demonstrated as the least reliable due to practice effects, measurement error and the regression to the mean phenomenon. [ 4 ]


Subsequent studies have compared "on-pump" CABG to  off-pump coronary artery bypass  (OPCAB)—essentially establishing controls to compare the incidence of neurocognitive decline in CABG with and without the use of CPB.  A small study (60 patients total, 30 in each treatment arm) by Zamvar et al. demonstrated neurocognitive impairment was worse for the on-pump group both 1 week and 10 weeks postoperatively. [ 5 ]   A larger study (281 patients total) by Van Dijk et al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months. [ 2 ]   Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life,  stroke  rate, or all-cause  mortality  at 3 and 12 months.  A study by Jenson et al. published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or conventional on-pump CABG. [ 1 ]


A study by McKhann et al. [ 6 ]  compared the neurocognitive outcome of people with  coronary artery disease  (CAD) to heart-healthy controls (people with no cardiac risk factors).  People with CAD were subdivided into treatment with CABG, OPCAB and non-surgical medical management. The three groups with CAD all performed significantly lower at baseline than the heart-healthy controls.  All groups improved by 3 months, and there were minimal intrasubject changes from 3 to 12 months.  No one consistent difference between the CABG and off-pump patients was observed.  The authors concluded patients with long-standing coronary artery disease have some degree of cognitive dysfunction secondary to  cerebrovascular  disease before surgery; there is no evidence the cognitive test performance of bypass surgery patients differed from similar control groups with coronary artery disease over a 12-month follow-up period.  A related study by Selnes et al. [ 7 ]  concluded patients with coronary artery bypass grafting did not differ from a comparable nonsurgical control group with coronary artery disease 1 or 3 years after baseline examination. This finding suggests that late cognitive decline after coronary artery bypass grafting previously reported by Newman et al. may not be specific to the use of cardiopulmonary bypass, but may also occur in patients with very similar risk factors for cardiovascular and cerebrovascular disease. [ 3 ]


In 2020, Australian film director  Andrew Pike  released  Pumphead , a documentary about the condition. The film explores the experiences of eight patients following major heart surgery, describing their experiences with postperfusion syndrome. The filmmaker Andrew Pike experienced pumphead himself, following open-heart surgery in 2011. [ 8 ]  The film introduces the concept of  post-traumatic growth , as a positive psychological change that can follow traumatic experiences such as pumphead. [ 8 ]


Pulmonary Artery Banding  ( PAB ) was introduced by Muller and Dammann in 1951 as a surgical technique to reduce excessive pulmonary blood flow in infants suffering from  congenital heart defects . [ 1 ]  PAB is a  palliative  operation as it does not correct the problems, but attempts to improve abnormal heart function, relieve symptoms and reduce high pressure in the lungs. The use of PAB has decreased over the years due to advancements in definitive surgical repairs, however PAB still has widespread clinical use. PAB is commonly used in patients when definitive surgical repair is not feasible. [ 2 ] [ 3 ]


The technique was first described by Muller and Dammann at  UCLA  in 1951. [ 4 ]  In recent years, the use of this technique has declined as studies have indicated that early definitive repair is preferable to this form of palliation. [ 5 ]


The heart is separated into four chambers. Deoxygenated blood enters into the right chambers of the heart and continues through the pulmonary arteries to be oxygenated in the lungs. Oxygenated blood returns into the left side of the heart and out to the rest of the body, known as the  systemic circulation . In congenital heart defects such as  ventricular septal defects  (VSD) and  Atrioventricular septal defects  (AVSD), there may be one or multiple holes in the walls separating adjacent chambers. This causes left-to-right shunting of blood as oxygenated blood can flow back to the right side of the heart, resulting in a mixture of oxygenated and deoxygenated blood. Increased amounts of blood on the right side of the heart cause an excess of blood flow into the lungs ( pulmonary circulation ) and increased pulmonary resistance due to the buildup of pressure. [ 6 ]


The goal of PAB is to reduce pulmonary artery pressure and excess pulmonary blood flow. PAB involves the insertion of a band around the pulmonary artery to reduce blood flow into the lungs. A variety of banding materials are used; one commonly used material is  polytetrafluoroethylene . [ 7 ]  The band is wrapped around the main pulmonary artery and fixed into place. Once inserted, the band is tightened, narrowing the diameter of the pulmonary artery to reduce blood flow to the lungs and reduce pulmonary artery pressure. PAB followed by later repair is a common surgical alternative when early definitive repair is high-risk. [ 8 ]


One major difficulty with PAB is assessing the optimal tightness of band, [ 9 ]  as minimal changes to the diameter of the pulmonary artery can have drastic effects on resistance and blood flow. The pulmonary band can also migrate away from the original placement and lead to  stenosis , [ 10 ]  in which the blood vessel becomes too narrow. There have also been reports of hardening of the vessels around the band due to buildup of calcium deposits and scarring of the pulmonary artery wall beneath the band, which can also inhibit blood flow. [ 11 ]  Additional surgeries to adjust band tightness occur in up to one-third of patients. [ 12 ]  Erosion of the band through the pulmonary artery has been reported, which can lead to the formation of blood clots. This is more evident in bands made of umbilical tape or silk rather than Silastic or Teflon bands. [ 13 ]


Due to the varying complications, different modifications of PAB have been developed to improve outcomes. Adjustable pulmonary artery banding has been available since 1972, [ 14 ]  allowing variable constriction.  FloWatch  (Leman Medical, Geneva, Switzerland: www.lemanmedical.com), an adjustable band, was created and has successfully been tested to overcome complications due to non-optimal sizing of the band.  FloWatch  is a wireless, battery-free, implantable device that allows the band size to be adjusted without the need for additional surgeries or other invasive procedures. [ 15 ]  The narrowing of the pulmonary artery can be controlled weeks or even months after the operation. [ 16 ]  Reports also show that the recovery period in patients that obtained the  FloWatch  device was faster and smoother in comparison to those that received the traditional PAB method. [ 17 ]  However  FloWatch  is only suitable for children with a body weight ranging from 3 kg to10kg. [ 18 ]


The  Rastelli procedure  is an  open heart   surgical  procedure developed by  Italian   physician  and  cardiac  surgery  researcher ,  Giancarlo Rastelli , in 1967 at the  Mayo Clinic , and involves using a pulmonary or aortic homograft conduit to relieve pulmonary
obstruction in double outlet right ventricle with pulmonary stenosis. [ 1 ]


On July 26, 1968, the first successful surgery was carried out at the Mayo Clinic by Dr. Robert Wallace.


It is used to correct certain combinations of  congenital   heart defects  ( CHD s):


The Rastelli procedure is typically performed between one and two years of age. Since d-TGA, overriding aorta and DORV are  cyanotic heart defects , the child is palliated with a  Blalock–Thomas–Taussig shunt  in the meantime.


Oxygenated blood is directed from the  left ventricle  to the  aorta  using a  Gore-Tex  patch. The VSD is also sealed with the patch. The  pulmonary valve  is surgically closed.


From the  right ventricle  to the  pulmonary bifurcation , a synthetic  conduit  and a valve are constructed, which lets oxygen depleted blood to flow into the lungs for reoxygenation. [ 3 ]


In the last seven years of the study, there were seven early deaths (7%) and no surgical fatalities. Univariable analysis revealed that a straddling tricuspid valve (P =.04) and longer aortic crossclamping periods (P =.04) were risk factors for early mortality.


There were 17 late deaths and a patient who had undergone heart transplantation after an average follow-up of 8.5 years.


44 patients underwent reoperations for conduit  stenosis , 11 for left ventricular outflow tract obstruction and 28 for interventional  catheterization  to alleviate conduit stenosis.


There were nine patients with late arrhythmias and five patients who experienced sudden deaths.


At 5, 10, 15 and 20 years, avoidance of death or transplantation (Kaplan-Meier) was 82 percent, 80 percent, 68 percent and 52 percent, respectively.


At 5, 10 and 15 years of followup, the rates of death or reintervention (catheterization or surgical therapy) were 53 percent, 24 percent and 21 percent, respectively. [ 4 ]


Overall, the Rastelli procedure has a low initial fatality rate.


Conduit blockage, left ventricular outflow tract obstruction and  arrhythmia , on the other hand, are linked to significant late morbidity and mortality. [ 4 ]


Almost half of the patients who received the Rastelli operation required heart transplantation or died two decades later.


A  resuscitative thoracotomy  (sometimes referred to as an  emergency department thoracotomy (EDT) ,  trauma thoracotomy  or, colloquially, as " cracking the chest ") is a  thoracotomy  performed to aid in the  resuscitation  of a  major trauma  patient who has sustained severe  thoracic  or  abdominal trauma . [ 1 ]  The procedure allows immediate direct access to the  thoracic cavity , permitting rescuers to control  hemorrhage , relieve  cardiac tamponade , repair or control major injuries to the heart, lungs or thoracic  vasculature , and perform direct  cardiac massage  or  defibrillation . The procedure is rarely performed and is a procedure of last resort. [ 2 ] : 462  [ 3 ]


A resuscitative thoracotomy is indicated when severe injuries within the thoracic cavity (such as  hemorrhage ) prevent the physiologic functions needed to sustain life. The injury may also affect a specific organ such as the heart, which can develop an  air embolism  or a  cardiac tamponade  (which prevents the heart from beating properly). The primary indication for a resuscitative thoracotomy is a patient with  penetrating  chest trauma who has entered or is about to enter  cardiac arrest . [ 4 ]  Other indications for the use of this procedure include the appearance of blood from a  chest tube  that returns more than 1500 mL of blood during the first hour of placement, or ≥200 mL of blood per hour two to four hours after placement. [ 5 ]


For resuscitative thoracotomy to be indicated, signs of life must also be present, including  cardiac electrical activity  and a  systolic blood pressure  >70 mm Hg. [ 2 ] : 462  [ 6 ]  In  blunt trauma , if signs of life, such as eye dilatation, are found en route to the hospital by first responders, but not found when the patient arrives, then further resuscitative interventions are contraindicated; however; when first responders find signs of life (respiratory or motor effort, cardiac electrical activity, blood pressure, or pupillary activity) [ 7 ]  and  cardiopulmonary resuscitation  time is under 15 minutes, the procedure is indicated. [ 8 ]


The use of a  focused assessment with sonography for trauma  may be performed to determine the need of the procedure by finding free floating fluid in the thoracic cavity. [ 9 ]


A left anterolateral thoracotomy is the common method of opening the chest, as it provides rapid access, can be easily extended into the right hemithorax, and provides access to most of the important anatomical structures during resuscitation including the  aorta . [ 10 ]  First an incision is made along the fourth or fifth  intercostal space  (between the ribs), intercostal muscles and the parietal  pleura  are divided, and then the ribs are retracted to provide visualization. [ 6 ]  When the incision covers both the right and left hemithoraxes it is referred to as a "clamshell" thoracotomy. The clamshell thoracotomy is used when there is a right sided  pulmonary  or  vascular  injury, or when greater access or visualization is desired. [ 2 ] : 242


Usually those who undergo resuscitative thoracotomy do not recover—only 10% of those receiving it after sustaining a blunt injury, and 15–30% of those with penetrating trauma survive. [ 10 ] [ 11 ] [ 2 ] : 240   Patients with thoracic stab wounds and patients who arrive at the emergency department with signs of life are associated with the highest rates of survival. Patients with  polytrauma  and patients who present without signs of life are associated with the lowest rates of survival. [ 12 ]


The procedure was first utilized during the late 1800s by Schiff in conjunction with open cardiac massage. Shortly after it was also used by Block to treat heart  lacerations , and the first suture repair performed in 1900. [ 13 ]  Before external  defibrillation  and  cardiopulmonary resuscitation  came in the 1960s, emergency thoracotomy was the preferred way to treat cardiac arrest. [ 2 ] : 236


Retrograde autologous priming  ( RAP ) is a means to effectively and safely restrict the hemodilution caused by the direct homologous blood transfusion and reduce the  blood transfusion  requirements during  cardiac surgery . [ 1 ]  It is also generally considered a blood conservation method used in most patients during the  cardiopulmonary bypass  (CPB). [ 1 ]  The processing of RAP includes three main steps, and the entire procedure of RAP (about 1L CPB prime volume) could be completed within 5 to 8 minutes. [ 2 ]  This technique is proposed by Panico in 1960 for the first time and restated by Rosengart in 1998 to eliminate or reduce the risk of hemodilution during CPB. [ 2 ]  Moreover, to precisely determine the clinical efficacy of RAP, many related studies were conducted. Most results of researches indicate that RAP is available to provide some benefits to reducing the requirements for  red blood cell  transfusion. [ 2 ]  However, there are still some studies showing a failure of RAP to limit the hemodilution after the open heart operation. [ 3 ]


The requirement of blood transfusion during open-heart surgical operations is almost inevitable because the  metabolism  must be continuously kept working through the peripheral blood flow. [ 4 ]  Cardiopulmonary bypass (CPB) is a medical technique to oxygenate the blood and remove the  carbon dioxide  during the cardiac operation. [ 4 ]  It can be seen as a “pump” to serve as a  heart-lung machine  whose function is sustaining blood circulatory and transporting  oxygen  to red blood cells before blood is flowing backwards the arterial circulation. [ 4 ]  It is also can be considered a kind of  extracorporeal  circulation. [ 4 ]


There are two primary methods, homologous blood transfusion and  autologous blood transfusion , to reduce the massive blood loss resulted from different surgeries. [ 5 ]  Homologous blood transfusion refers to using blood from other compatible donors to improve the oxygen-carrying capacity for blood by raising the number and concentration of blood red cells. [ 6 ]  Autologous transfusion uses patients' own blood which is stored previously. [ 5 ]  Compared to autologous blood transfusion, the homologous blood transfusion has more side effects, such as postoperative  Infection ,  immunosuppression  and viral  transmission . [ 7 ]  These  adverse effects  facilitate the development of approaches to conserve the blood during cardiac surgery. [ 1 ]  These methods contain preoperative autologous blood donation (PABD), acute normovolemic hemodilution (ANH) and  cell salvage . [ 1 ]  There are two main ways to salvage red blood cells. Cell processing and direct injection. Cell processors are red cell washing devices like the Cell Saver that collect anticoagulated shed or recovered blood, wash and separate the  red blood cells  (RBC) by centrifugation. Filtration devices like HemoClear microfilter, constitute the second major type of blood salvage in operating rooms. In general, ultrafiltration devices filter the patient's anticoagulated whole blood. [ 8 ]  Direct transfusion is a blood salvaging method associated with  cardiopulmonary bypass  (CPB) circuits or other extracorporeal circuits (ECC) that are used in surgery such as coronary artery bypass grafts ( CABG ), valve replacement, or surgical repair of the great vessels. Following bypass surgery, the ECC circuit contains a significant volume of diluted whole blood that can be harvested in transfer bags and re-infused into patients.


Furthermore, the number of patients requiring red blood transfusions could be anticipated by observing a variety of variables before cardiac surgery. [ 2 ]  The  red cell mass , as a critical factor, it matches the assumption that the blood transfusion is commonly demanded by patients who have a low red cell mass during CPB. [ 2 ]  At the same time, these patients are more likely to have low  hematocrit  values. [ 2 ]  Patients expect to reduce the blood product used during surgery because the red blood transfusion generally has a negative physiologic impact and highly related cost. [ 2 ]  Especially when CPB is applied in surgical operations, there will be a large number of blood transfusions required due to blood loss and hemodilution. [ 2 ]


Furthermore, a significant risk caused by the homologous blood transfusion in open-heart surgeries is hemodilution. [ 1 ]  The hemodilution is the primary hematologic interference which results in  coagulopathy  and decreased capability of carrying oxygen in the blood. [ 9 ]  The root cause of this situation is the decreased blood concentration and  viscosity  in the body. [ 10 ]  During the cardiopulmonary bypass, blood is mixed directly through the homologous blood transfusion, but homologous blood may be not compatible, acceptable or available. [ 10 ]  Thus, there is a  high incidence of distinct degrees of hemodilution with CPB. [ citation needed ]


RAP is a blood conservation technique to decrease the priming volume of cardiopulmonary bypass and then reduce the level of the hemodilution. [ 1 ]   To be more specific, some cardiopulmonary bypass circuit prime are replaced by autologous circulating blood at the beginning of bypass in both venous  cannula  and arterial cannula. [ 1 ]  The final objective of RAP is reducing the number of patients requiring blood transfusion during CPB. [ 1 ]


There is a type of  glycoprotein  growth factor - erythropoietin that can be used to mitigate the hemodilution by increasing the total number of red blood cells. [ 11 ]  Compared with  erythropoietin , RAP is more rapid and inexpensive. [ 1 ]  Because RAP aims to directly influence the CPB prime volume instead of red cell masses, but for patients who have extremely low red cell masses, like  anaemic  patients and some particular groups, such as women and elderly, they would have greatly decreased hematocrit values and need a larger amount of blood transfusions. [ 1 ]  As a consequence, these patients are thought to be more suitable to use erythropoietin rather than RAP. [ 1 ]


The specific procedure of RAP was firstly described by Rosengart and DeBois to restrict the hemodilution during CPB. [ 12 ]  When arterial cannulae and venous cannulae are prepared, the  crystalloid  prime (approximately 1L) is drained into a re-circulation bag. [ 12 ]  Before the beginning of the CPB, the crystalloid priming fluid is displaced by the autologous blood. [ 12 ]  There are three key steps for RAP to have a role to play. [ 12 ]  The first step is that crystalloid is flowing from the  arterial line  into the transfer bag. [ 12 ]  And then autologous blood flows through the arterial line and filter after the placement of arterial cannulae. [ 12 ]  The second step is crystalloid prime in the venous reservoir and  oxygenator  is replaced by blood through pressure gradients. [ 12 ]  Lastly, the remaining crystalloid priming fluid is collected and displaced from the venous line into the CPB bag on the onset of CPB. [ 13 ]  In each step, about 300ml CPB crystalloid prime volume is replaced by blood into the transfer bag. The entire process could be commonly finished within 5 to 8 minutes. [ 12 ]


Although RAP is an effective and safe technique to reduce the hemodilution during CPB, there are still some potential risks of RAP.


The first risk is related to blood  viscosity . [ 1 ]  The blood viscosity refers to the resistance to the movement of blood. It is vital to sustaining the vascular  homeostasis  in disease prevention and medical treatment. [ 14 ]  Besides, the blood viscosity is greatly influenced by distinct factors, such as haematocrit, the degree of aggregation of the blood red cells and temperature. [ 14 ]  Some researchers support the inverse relationship between temperature and blood viscosity. [ 15 ]  They calculated that the blood viscosity increased by two percent for each degree of the temperature drop. [ 15 ]  And then it would bring in hematologic concentration and increased hematocrit. [ 1 ]  During CPB, blood viscosity can rise 10% to 30% at low temperature. [ 1 ]  Thus, an appropriate degree of hemodilution is considered to be helpful to reduce the increased blood viscosity and the adverse effect of  microcirculation . [ 1 ]  Furthermore, this kind of degree of hemodilution is often given by an entire crystalloid prime. [ 1 ]  When some crystalloid prime is replaced by RAP during CPB, the blood viscosity may increase and then generate a negative impact on patients undergoing cardiac surgery. [ citation needed ]


The second potential risk is about  hemodynamic  instability. [ 1 ]  The hemodynamic instability could be defined as the  perfusion  failure, which gives rise to unstable  blood pressure . It is characterized by some clinical features, such as  circulatory shock  and advanced  heart failure . [ 16 ]  When RAP is used, the large amount of crystalloid prime is extracted, and then the withdrawal theoretically results in the hemodynamic instability. [ 1 ]  The hemodynamic instability is a treatable condition if  phenylephrine  and crystalloid administration could be applied. [ 2 ]  However, the therapeutic effectiveness of RAP reduces because of the crystalloid administration to some extent. If hemodynamic instability cannot be eliminated throughout the treatment, RAP must be stopped. [ 2 ]


In 2004, a retrospective cohort research was designed to test the clinical effectiveness of RAP during CPB. [ 3 ]  Two hundred and fifty-seven participants were allocated into the  experimental group  which used RAP as a routine medical technique to conserve blood. In the meantime, two hundred and eighty-eight participants were grouped without RAP. [ 3 ]  The period for this research is twenty-four months. [ 3 ]  A significantly small reduction of requirements for blood transfusion is founded in the RAP group, and no difference is observed between two groups for the number of  packed red cell blood  units. This result supports that RAP is failing to provide benefits to the blood protection during cardiac surgery. [ 3 ]  However, in a subsequent 2006 study by the same authors, it was found that RAP patients had improved post-operative outcomes and significantly fewer post-operative cardiac arrests.


A multimodal method might be beneficial to conserving crucial  organ perfusion  and decreasing requirements of blood transfusions. [ 2 ]  Moreover, approaches which are objective to restrict intraoperative  fluid balance  positiveness may also contribute to reduced blood transfusions because positive intravenous fluid balance plays a critical role in limiting hemodilution during open-heart operations. [ 2 ]


Plasma  concentration filters are functional to remove extra fluid at the onset of CPB. [ 2 ]  Hemoconcentration can be defined as the increased concentration of blood cells that results from the decreased plasma volume. Hemoconcentration may lead to some potential  complications , such as  embolism , infection and  haemolysis . [ 2 ]  To avoid the lack of circulating volume, the additional CPB is usually used during  hemofiltration . [ 2 ]  However, the additional CPB may mitigate the effect of hemofiltration, and the efficacy of hemofiltration on blood transfusion is not significantly clear. [ 2 ]  So the  ultrafiltration  cannot be verified as a useful blood conservation technique to reverse hemodilution and maintain blood balance. [ 2 ]


Autologous blood cell salvage is a therapeutic approach to recover the blood during cardiac surgery. Today, it is also widely used in many other high risk of surgeries around the world. [ 2 ]  Some reports suggest that if autologous blood cell salvage is routinely used in open heart surgeries, the requirements for blood transfusions can be effectively reduced. [ 2 ]  Moreover, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists guidelines argued that the routine use of intraoperative blood salvage is beneficial to blood conservation during CPB. [ 20 ]  However, it is not available to patients who have infection or  malignancy . [ 2 ]


The  Ross procedure , also known as  pulmonary autograft , is a  heart valve replacement operation  to treat severe  aortic valve disease , such as in children and young adults with a  bicuspid aortic valve . [ 1 ]  It involves removing the diseased  aortic valve , situated at the exit of the  left side of the heart  (where the  aorta  begins), and replacing it with the person's own healthy  pulmonary valve  (autograft), removed from the exit of the  heart's right side  (where the  pulmonary artery  begins). [ 4 ]  To reconstruct the right-sided exit, a pulmonary valve  from a cadaver  (homograft), or a stentless  xenograft , is used to replace the removed pulmonary valve. [ 1 ] [ a ]  Compared to a  mechanical valve replacement , it avoids the requirement for  thinning the blood , has favourable  blood flow dynamics , allows growth of the valve with growth of the child and has less risk of  endocarditis . [ 1 ]


It is not performed if  Marfan syndrome , pulmonary valve disease, or immune problems like  lupus  are present. [ 3 ]  Other contraindications include severe  coronary artery disease  and severe mitral valve disease. [ 3 ]  Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root is present. [ 6 ]  Complications include  endocarditis , degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [ 1 ] [ 2 ]  It risks having a disease of two valves instead of one. [ 7 ]


The procedure requires technical expertise. [ 4 ]  It can be performed using the traditional subcoronary method or more commonly the root replacement technique, which requires re-implanting the coronary arteries. [ 8 ] [ 9 ]


After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. [ 10 ]  It may need reoperating on at a later date. [ 7 ]  Complications occur in 3 to 5% of cases, with early death rate almost negligible in very experienced centres. [ 3 ]  80% to 90% of cases survive 10 years. [ 3 ]  As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [ 1 ]


The procedure was first performed using the subcoronary method in 1967 by  Donald Ross , for whom the procedure is named. [ 8 ] [ 11 ]  The root replacement method was introduced in the early 1970s. [ 8 ]  It was continued and modified by others such as  Magdi Yacoub , who used fresh valves from the explanted hearts of transplant recipients. [ 11 ]


Several adaptations of the Ross procedure have evolved, but the principle is essentially the same; to replace a diseased  aortic valve  with the person's own  pulmonary valve  (autograft), and replace the person's own pulmonary valve with a pulmonary valve  from a cadaver  (homograft) or a stentless  xenograft . [ 1 ] [ 4 ]  It is an alternative to a  mechanical valve replacement , particularly in children and young adults. [ 7 ]  It avoids the need for  thinning the blood , has favourable  blood flow dynamics  and the valve grows as the person grows. [ 7 ]


The most common reason for performing the Ross procedure in children and young adults is for bicuspid aortic valve. [ 1 ]


It is not performed in  Marfan syndrome , if pulmonary valve disease, or if immune problems like  lupus . [ 3 ]  Other contraindications include severe  coronary artery disease  and severe mitral valve disease. [ 3 ]  Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root. [ 6 ]


The procedure requires technical expertise, and risks converting a single-valve disease into double-valve disease. [ 4 ]  It may need re-operating on at a later date. [ 7 ]  Complications include  endocarditis , degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. [ 1 ] [ 2 ]


Before the operation, preparations include  transthoracic echocardiography  and measurements of the  ascending aorta  and the pulmonary valve. [ 10 ]  Under  general anaesthesia , the chest is cut  open in the midline . [ 3 ]  The heart and aorta are exposed before the  heart is temporarily stopped  and its function taken over  cardiopulmonary bypass . [ 3 ]  Subsequent steps include removing the diseased aortic valve and mobilizing the  coronary arteries , followed by harvesting and preparing the person's own healthy pulmonary valve, before implanting it within the  left ventricular outflow tract , the exit of the  left side of the heart  (where the  aorta  begins). [ 1 ] [ 10 ]  Then the coronary arteries are reimplanted, before the pulmonary homograft is implanted in the  right ventricular outflow tract , the exit of the  heart's right side  (where the  pulmonary artery  begins). [ 1 ] [ 10 ]  The pulmonary autograft is joined to the ascending aorta. [ 1 ] [ 10 ]


Cryopreserved  pulmonary homografts were most often used for a long time until the introduction of  decellularized homografts . [ 2 ]


If the left sided outflow root needs to be enlarged to fit the pulmonary autograft, the procedure is called Ross-Konno. [ 3 ]  An alternative to a pulmonary homograft is the stentless  xenograft  roots such as the Freestyle Porcine Aortic Root by  Medtronic . [ 2 ] [ 12 ]  An external Dacron graft can be used to reinforce the pulmonary autograft. [ 2 ]


After the operation, good blood pressure control prevents early dilatation of the new aortic root and allows the pulmonary autograft, now in the aortic position, to settle in its new environment. [ 10 ]  Aftercare includes regular echocardiography and lifelong endocarditis prophylaxis. [ 1 ]


Complications occur in 3% to 5% of cases with one to 3% chance of early death. The death rate is almost negligible in very experienced centres. 80% to 90% of cases survive 10 years, and 70% to 80% may live up to 20 years. [ 3 ]  As of 2014, the Ross procedure comprises less than 1% of all aortic valve replacements in North America. [ 1 ]


Replacing a diseased aortic valve with an aortic valve from a cadaver was first performed by  Donald Ross  in England in June 1962, and shortly after in July 1962 by  Brian Barratt-Boyes  in Auckland, New Zealand. [ 11 ] [ 13 ]  In 1967 Ross took the normal pulmonary valve of a person with severe aortic valve disease, and placed it in the aortic position where the diseased aortic valve was removed. [ 11 ]  To reconstruct the missing pulmonary outflow tract, a homograft stored and sterilised from a cadaver was used to replace the removed pulmonary valve. [ 11 ]  In 1972, Ross introduced the technique using the root replacement method. [ 13 ]  For 30 years he was almost the only surgeon performing the procedure, until it gained popularity. [ 11 ]   Marian Ionescu  in Leeds, in an attempt to seek other materials, unsuccessfully tried  fascia lata  from the person's own thigh to create a living valve. [ 11 ]  He then tried successfully with cattle pericardium fixed with  glutaraldehyde , and the procedure became widespread before then falling out of favour as they failed. [ 11 ]  Then came pig valves (xenograft) before the 1980s trend for mechanical valves. [ 11 ]  The Ross procedure was continued and modified by  Magdi Yacoub , who used fresh valves from the explanted hearts of transplant recipients. [ 11 ]


It has also been called the double-switch Ross procedure. [ 14 ]


In 1997, to replace a  bicuspid aortic valve , the Ross procedure was performed on  Arnold Schwarzenegger . [ 15 ]


The procedure was more popular in the 1990s and then declined in use over the subsequent 20 years. [ 16 ]  Data relating to the procedure is held in the Ross registry. [ 17 ]


The procedure has been carried out in pigs and sheep for the purpose of research. [ 18 ]


A  Sano shunt  is a shunt from the  right ventricle  to the  pulmonary circulation . [ 1 ] [ 2 ] [ 3 ]


In contrast to a  Blalock–Taussig shunt , circulation is primarily in  systole . [ citation needed ]


It is sometimes used as the first step in a  Norwood procedure . [ citation needed ]


This procedure was pioneered by the  Japanese   cardiothoracic surgeon   Shunji Sano  [ ja ]  in 2003. [ 4 ]


Eileen Saxon , sometimes referred to as "The Blue Baby", was the first patient that received the operation now known as  Blalock–Thomas–Taussig shunt .


She had a condition called  Tetralogy of Fallot , one of the primary congenital defects that lead to  blue baby syndrome . In this condition, defects in the great vessels and wall of the heart lead to a chronic lack of  oxygen  in the blood. In Eileen's case, this made her lips and fingers turn blue, with the rest of her skin having a very faint blue tinge. She could only take a few steps before beginning to breathe heavily.


On November 29, 1944, Saxon was the first living human to receive a groundbreaking operation. [ 1 ] [ 2 ]  (now known as a  Blalock-Thomas-Taussig shunt ) suggested by  pediatric   cardiologist   Helen B. Taussig  and administered by  Alfred Blalock , with  Vivien Thomas , who had perfected the surgery in laboratory tests on animals, standing over his shoulder to advise him on performing the surgery. [ 3 ] [ 4 ]


The surgery had been designed and first performed on laboratory dogs by Thomas, who taught the technique to Blalock. Although Thomas perfected the technique, he could not perform the surgery because he was not a doctor.


The surgery was not completely successful, since Eileen Saxon became  cyanotic  again a few months later. Another shunt was attempted on the opposite side of the chest, but she died a few days afterwards, very close to her second birthday. Though Saxon died, she lived long enough to demonstrate that the operation would work. The team later discovered the operation worked best in older children. Saxon herself could not have waited any longer. By the time the first shunt was attempted on her, she was in danger of dying.


Eileen Saxon's surgery was re-enacted in the documentary  Partners of the Heart , produced by  Spark Media , and broadcast on  American Experience  in 2003.  [ 5 ]


The 2004 movie produced by  HBO ,  Something The Lord Made , is a dramatic feature based on the Saxon baby operation.


The  Senning procedure  is an  atrial switch  heart operation performed to treat  transposition of the great arteries . It is named after its inventor, the Swedish cardiac surgeon  Åke Senning  (1915–2000), also known for implanting the first permanent cardiac  pacemaker  in 1958.


This procedure, a form of  atrial switch , was developed and first performed by Senning in 1957 as a treatment for d-TGA ( dextro-Transposition of the great arteries ) before improvements in  cardiopulmonary bypass  made more curative surgical techniques feasible. [ 1 ]  In this congenital heart defect, the venous circulation drains into the right ventricle but from this chamber, blood is directed towards the systemic circulation through the aorta. This is also expressed by the term ventriculoarterial discordance, that is the ventricles are connected to the wrong great artery (the right ventricle to the aorta, thus pumping blood from the systemic venous back into the systemic arterial circulation).
Thus, d-TGA is not to be confused with  l-TGA , where there is both atrioventricular and ventriculoarterial discordance. [ citation needed ]


In the absence of a shunt, patients with d-TGA could not survive because there would be no flow of oxygenated blood (coming from the pulmonary veins) to the rest of the body after the normal prenatal shunts physiologically close a few weeks after birth.
This congenital heart defect caused babies to "turn blue" due to the lack of oxygen flowing through the blood. [ 2 ] [ 3 ]  Before this technique became available, in 1950, two cardiac surgeons, Blalock and Hanlon, had developed a palliative procedure that consisted of opening the atrial septum. [ 1 ]  Since, in TGA, the atrial septum prevents oxygenated blood from reaching the systemic circulation, this simpler procedure leads to improvements in systemic arterial O2 saturation. [ citation needed ]


With the Senning surgical repair, a baffle – or conduit - is created within the atria that reroutes the deoxygenated blood coming from the inferior and superior vena cavae to the mitral valve and therefore to the pulmonary circulation  [ 4 ]  This is accomplished by creating a systemic venous  conduit that channels deoxygenated blood from the superior and inferior vena cava towards the mitral valve. After this complex plastic reconstruction using flaps from the right atrial tissue and the interatrial septum, it lets the oxygenated pulmonary venous blood flow to the tricuspid valve and from there to the systemic circulation. The anatomic left ventricle continues to pump into the pulmonary circulation and the anatomic right ventricle will work as the systemic pump, in other words, the ventriculo-arterial mismatch is left unrepaired.
In the Senning's operation, atrial tissue is used to create the baffle. No prosthetic material is introduced. A complex work of incising and refolding the native atrial tissue - which is so technically complex that has been referred to as "origami", is necessary to build the venous baffle. Indeed, the Senning technique was difficult to reproduce and was not widely embraced. [ citation needed ]


In 1963, Mustard described an alternative technique, the  Mustard procedure , in which the atrial septum is excised, and the atrial baffle is created by the placement of a single elephant trunk-shaped patch made of pericardial tissue. This technique then became the standard operation for TGA as it was technically less demanding.


Currently, the arterial switch or  Jatene procedure  is the preferred surgical corrective method. In this technique, the great arteries are excised and reimplanted to the corresponding ventricles. The Brazilian surgeon Jatene performed the first procedure in 1975. The coronary arteries are also explanted from the anatomical aorta, which lies on the venous side and reattached to the systemic great vessel. Indeed, the initial difficulties that prevented an earlier adoption of this approach were mostly the inability to transfer the coronary arteries, besides problems with early forms of cardiopulmonary bypass that made cardiac surgery in early infancy less safe than in the present times  [ 4 ]  Some individuals with d-TGA are not candidates for an arterial switch, particularly because of late diagnosis, coexistent VSD with associated pulmonary hypertension, inadequate left ventricular function, or complex coronary abnormalities. [ 1 ]  Moreover, the Senning procedure is used as part of the double switch surgical correction of l-TGA ( Senning-Rastelli procedure).


The acute mortality associated with the Senning procedure is reported to be around 5-10%. Patient selection and the complexity of the congenital malformation are determinants of mortality risk. Patients who have undergone such surgical correction of the congenital transposition are exposed to long-term risks of cardiovascular events. In particular, sinus node dysfunction, atrial arrhythmias, ventricular arrhythmias including sudden cardiac arrhythmic death, heart failure due to anatomically right ventricular failure, or venous obstruction at the level of the baffle or caval anatomy have been described. The high chance of developing arrhythmias results in up to 25% of patients who have undergone a Senning or Mustard procedure having a pacemaker by adulthood. [ 5 ]


Long-term studies have disclosed that although from the functional capacity standpoint the Senning and the Mustard operation are similar, there is a higher risk of sinus node disease and arrhythmias with the latter. [ 6 ]  Overall, in most studies, survival is good into the second decade post-procedure. 78% of patients were alive after 16 years in a large follow-up study from the Netherlands. [ 7 ]


Before the utilization of surgical repair, Kirklin reports that the mortality associated with unrepaired TGA was 55%, 85%, and 90% mortality rates at 1 month, 6 months, and 1 year, respectively. These numbers correspond to all types of TGA. [ 8 ]  A major factor affecting long-term morbidity and mortality is the coexistence of a  ventricular septal defect  (VSD). Patients with a concomitant VSD may have also developed pulmonary vascular disease.


Septal myectomy  is a  cardiac surgery  treatment for  hypertrophic cardiomyopathy  (HCM). [ 1 ]  The open-heart surgery entails removing a portion of the  septum  that is obstructing the flow of blood from the left  ventricle  to the  aorta . [ 2 ]


The most common alternatives to septal myectomies are treatment with medication (usually  beta  or  calcium blockers ) or non-surgical thinning of tissue with  alcohol ablation . Ordinarily, septal myectomies are performed only after attempts at treatment with medication fail. The choice between septal myectomy and alcohol ablation is a complex medical decision. [ citation needed ]


Septal myectomy was established by  Andrew G. Morrow  in the 1960s. [ 3 ]


Septal myectomy is associated with a low perioperative mortality and a high late survival rate.  A study at the  Mayo Clinic  found surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation.   The results are shown below: [ 4 ]


Either alcohol ablation or myectomy offers substantial clinical improvement for patients with  hypertrophic obstructive cardiomyopathy . One non-randomized comparison suggested that hemodynamic resolution of the obstruction and its sequelae are more complete with myectomy. [ 5 ]  Whether one or the other treatment is preferable for certain patient types is debated among cardiovascular scientists. [ 6 ]


Totally endoscopic coronary artery bypass surgery (TECAB)  is an entirely  endoscopic   robotic surgery  used to treat  coronary heart disease , developed in the late 1990s. It is an advanced form of  minimally invasive direct coronary artery bypass surgery , which allows bypass surgery to be conducted  off-pump  without opening the ribcage. The technique involves three or four small holes in the chest cavity through which two robotic arms, and one camera are inserted. [ 1 ] [ 2 ]


TECAB surgery uses the da Vinci tele-robotic  stereoscopic 3-D imaging  system. The system consists of a robotic "slave" system at the bedside. The robot relays its information to an external surgical control unit, where a  cardiac surgeon  has a three-dimensional view of the chest cavity, and twin controllers for the robotic arms. The procedure frequently involves  grafting  of the  internal mammary artery  to the  diseased coronary artery , and therefore does not require external harvesting of blood vessels. [ 3 ]


Valve replacement  surgery is the replacement of one or more of the  heart valves  with either an  artificial heart valve  or a bioprosthesis ( homograft  from human tissue or  xenograft  e.g. from pig). It is an alternative to  valve repair .


There are four procedures


Current aortic valve replacement approaches include closed heart surgery, Very invasive cardiac surgery (VICS) and Very invasive, Scapulae-based aortic valve replacement.


Catheter replacement of the aortic valve (called trans-aortic valve replacement or implementation [TAVR or TAVI]) is a minimally invasive option for those suffering from  aortic valve stenosis . TAVR is commonly performed by guiding a catheter from the groin to the narrowed valve via the aorta using realtime x-ray technology. A metal stent containing a valve is then deployed using a balloon to press the stent into the valve in effect opening the stenosed (or narrowed) valve and lodging the stent in place. The procedure was first approved in the United States in November 2011  [ 1 ]  as an alternative for people deemed a poor candidate for open approach replacement; however, TAVR has been successfully implemented into practice in other countries prior to 2011. [ 1 ]


In those between 50 and 70 years of age bioprosthetic and mechanical aortic valves have similar overall outcomes with respect to stroke and survival. [ 2 ]


Valve-sparing aortic root replacement  (also known as the  David procedure ) is a  cardiac surgery  procedure which is used to treat  Aortic aneurysms  and to prevent  Aortic dissection . [ 1 ]  It involves replacement of the  aortic root  without replacement of the  aortic valve .  Two similar procedures were developed, one by  Sir Magdi Yacoub , [ 2 ]  and another by  Tirone David . [ 3 ] [ 4 ]


The valve-sparing aortic root replacement allows for direct narrowing of enlarged aortas, which change the fluid dynamics of outbound blood from the heart, while preserving the natural tissues of the aortic valve, which means the patient does not have to rely on  anticoagulants . Common features of both techniques of the replacement process are the clamping of the aorta and the use of a length of  Dacron  tube (also known as an "aortic graft"), typically 5 cm, to constrict the aortic root to the normal diameter, while the patient is cooled to 20°C and placed on life support. The procedure typically takes 4 to 6 hours in healthy patients. [ 1 ] [ 5 ]


Established by  Sir Magdi Yacoub  in the mid-1990s, the process involves cutting the aorta superior of (slightly downstream of) the  aortic valve  and attaching the tube, one end of which has been shaped into a three-lobed wavy ring, directly to the  commissures  connecting the aortic valve to the aortic wall. In other words, the "sinotubular junction" holding the aortic valve in place is reformed with the tube flush with the outermost valve tissue, and extending between the valve's cusps. [ 6 ] [ 7 ]


Established by  Tirone E. David  and  Christopher Feindel  at the  Toronto General Hospital  in 2007, [ 8 ]  this technique differs in the shape of the Dacron tube's end, which here is a ring with a flat edge, and its location, with the sinotubular junction "inserted" into the tube. In other words, the tube acts like a "corset" on the outside of the wall surrounding the aortic valve, though the tube's attachment points are the same as in the Yacoub method. [ 9 ] [ 10 ] [ 11 ]


A 2023 literature review of David method patient outcomes after 2010 found that the chances of complications such as endocarditis and stroke, were reduced to 0.3%, while survival rates were 99% within a year and 89% within a decade afterward. The most common reason for follow-up (typically needed in 5 years) was minor chest bleeding, reported by 5.4% of patients. [ 12 ]


A  valvulotomy ,  valvotomy , [ 1 ]   valvuloplasty , or  valvoplasty  is a procedure used in heart valve surgery that consists of  making one or more incisions  at the edges of the  commissure  formed between the two (mitral valve), or three  tricuspid  valve leaflets. This relieves the constriction of  valvular stenosis  (especially  mitral valve stenosis ). [ citation needed ]


As with many other kinds of surgery, a valvulotomy may be carried out using by either  open  or  minimally invasive  approaches, and sometimes (but not invariably) the terms  surgery  and  surgical  are understood to refer only to the open types, with the minimally invasive types then being referred to as  interventional  procedures. The minimally invasive approach is through the  lumen  of a  vessel  with a  catheter , which is why it is often called a transluminal or transcatheter approach. Such approaches begin with a small skin incision to access a vessel that will lead to the heart, making them  percutaneous  approaches, and they use balloons whose inflation moves the valve leaflets. Thus, all together, they are called by names such as  percutaneous balloon valvulotomy ,  percutaneous balloon mitral valvuloplasty ,  percutaneous aortic balloon valvotomy , and so forth.


Vasoplegic syndrome  or  vasoplegia syndrome  ( VPS ) is a  postperfusion syndrome  characterized by low systemic  vascular resistance  and a high  cardiac output .


VPS occurs more frequently after on pump  CABG  surgery versus off pump CABG surgery. [ 1 ]   Hypothermia  during  surgery  may also increase ones risk of developing VPS post operatively. [ 2 ]


Vasoplegic syndrome is defined as low systemic  vascular resistance  (SVR index <1,600 dyn∙sec/cm 5 /m 2 ) and high cardiac output (cardiac index >2.5 L/min/m 2 ) within the first 4 postoperative hours. [ 3 ]


There is some evidence to support the use of  methylene blue  in the treatment of this condition. [ 4 ] [ 5 ]


One case series reports a rate of 1 in 120 cases. [ 6 ]


Ventriculectomy , or  ventricular reduction , is a type of operation in  cardiac surgery  to reduce enlargement of the  heart  from  cardiomyopathy  or ischemic aneurysm formation. In these procedures, part of the  ventricular  wall is resected. [ 1 ]  A  Batista procedure  is a partial left ventriculectomy that is used to treat advanced heart failure. [ 1 ]  This procedure is not widely used because outcomes are often unsatisfactory. [ 2 ]


The  Yasui procedure  is a pediatric heart operation used to bypass the  left ventricular outflow tract  (LVOT) that combines the aortic repair of the  Norwood procedure  and a shunt similar to that used in the  Rastelli procedure  in a single operation. [ 1 ] [ 2 ]  It is used to repair defects that result in the physiology of  hypoplastic left heart syndrome  even though both ventricles are functioning normally. These defects are common in  DiGeorge syndrome  and include  interrupted aortic arch  and  LVOT obstruction  (IAA/LVOTO);  aortic atresia - severe stenosis  with  ventricular septal defect  (AA/VSD); and aortic atresia with interrupted aortic arch and  aortopulmonary window . This procedure allows the surgeon to keep the  left ventricle  connected to the  systemic circulation  while using the  pulmonary valve  as its outflow valve, by connecting them through the ventricular septal defect. The Yasui procedure includes a modified  Damus–Kaye–Stansel procedure  to connect the  aortic  and  pulmonary roots , allowing the  coronary arteries  to remain perfused. [ 1 ]  It was first described in 1987. [ 3 ]


A Yasui procedure can be done instead of a  Norwood operation  in some cases of LVOT obstruction to avoid committing a child to a single-ventricle heart, or it can follow a Norwood operation when the surgeon uses a staged approach. It is also used when the  Ross procedure  or  Konno procedure  are not feasible in children who have had other surgeries to repair  coarctation of the aorta  or interrupted aortic arch. [ 4 ]


The Yasui procedure is done via a  median sternotomy  and uses  cardiopulmonary bypass . If there is a  patent ductus arteriosus , the surgeon begins by closing it. The surgeon then connects the separated parts of the aorta together. The surgeon then transects the  pulmonary artery  and  aorta  and frees them from surrounding tissue, then makes an incision into the  right ventricle  to allow them to assess the ventricular septal defect and remove excess muscle bundles in cases of extensive  right ventricular hypertrophy . If the ventricular septal defect is smaller than the pulmonary valve, the surgeon will enlarge the defect. The surgeon then uses a patch, commonly made of bovine (cow)  pericardium  or the child's own tissue, to create a tunnel between the ventricular septal defect and the pulmonary valve. This allows for blood to flow from the left ventricle to the pulmonary valve. After creating this tunnel, the surgeon connects the aortic and pulmonary roots (Damus-Kaye-Stansel anastomosis). [ 1 ]


Children typically have good cardiac function and survival after the Yasui procedure, similar to other operations for the same conditions. However, children may require re-operation to replace the conduit in their heart if they outgrow it. Long-term survival depends on other factors, such as genetic disease. [ 2 ] [ 5 ] [ 6 ]


' General'  surgery  is a  surgical specialty  that focuses on  alimentary canal  and  abdominal  contents including the  esophagus ,  stomach ,  small intestine ,  large intestine ,  liver ,  pancreas ,  gallbladder ,  appendix  and  bile ducts , and often the  thyroid gland . General surgeons also deal with diseases involving the  skin ,  breast ,  soft tissue ,  trauma ,  peripheral artery disease  and  hernias  and perform  endoscopic  as such as  gastroscopy ,  colonoscopy  and laparoscopic procedures.


General surgeons may sub-specialise into one or more of the following disciplines: [ 1 ]


In many parts of the world including  North America ,  Australia  and the  United Kingdom , the overall responsibility for  trauma care  falls under the auspices of general surgery. Some general surgeons obtain advanced training in this field (most commonly surgical critical care) and specialty certification surgical critical care. General surgeons must be able to deal initially with almost any surgical emergency. Often, they are the first port of call to critically ill or gravely injured patients, and must perform a variety of procedures to stabilize such patients, such as thoracostomy,  cricothyroidotomy , compartment fasciotomies and emergency  laparotomy  or  thoracotomy  to  stanch  bleeding. They are also called upon to staff surgical intensive care units or trauma intensive care units. [ citation needed ]


All general surgeons are trained in emergency surgery. Bleeding, infections, bowel obstructions and organ perforations are the main problems they deal with.  Cholecystectomy , the surgical removal of the gallbladder, is one of the most common surgical procedures done worldwide. This is most often done electively, but the gallbladder can become acutely inflamed and require an emergency operation. Infections and rupture of the  appendix  and small bowel obstructions are other common emergencies.


This is a relatively new specialty dealing with  minimal access techniques  using cameras and small instruments inserted through 3- to 15-mm  incisions.  Robotic surgery  is now evolving from this concept (see below). Gallbladders, appendices, and colons can all be removed with this technique. Hernias are also able to be repaired laparoscopically.  Bariatric surgery  can be performed laparoscopically and there a benefits of doing so to reduce wound complications in  obese  patients. General surgeons that are trained today are expected to be proficient in laparoscopic procedures.


General surgeons treat a wide variety of major and minor colon and rectal diseases including inflammatory bowel diseases (such as  ulcerative colitis  or  Crohn's disease ),  diverticulitis , colon and rectal cancer, gastrointestinal bleeding and hemorrhoids.


General surgeons can specialise in Upper Gastro-intestinal (or  foregut ) surgery, which includes the surgical treatment of diseases of the  stomach  and  oesophagus ,  liver ,  pancreas  and  gallbladder . [ 2 ]  In the UK, Upper GI surgeons can subspecialise further as benign surgeons, dealing with  hiatus hernias  and gallbladder diseases, bariatric surgeons, providing surgical care for  weight management  and metabolic diseases, or oesophago-gastric surgeons, dealing with complex problems related to the upper gastrointestinal tract (the foregut), including cancer. Surgical care of complex liver and pancreatic problems (including  liver cancer  and  pancreatic cancer ) is undertaken by  Hepatobiliary and Pancreatic Surgery  sub-specialists.


General surgeons perform a majority of all non-cosmetic breast surgery from lumpectomy to  mastectomy , especially pertaining to the evaluation, diagnosis and treatment of  breast cancer .


General surgeons can perform vascular surgery if they receive special training and certification in vascular surgery. Otherwise, these procedures are typically performed by vascular surgery specialists. However, general surgeons are capable of treating minor vascular disorders.


General surgeons are trained to remove all or part of the thyroid and  parathyroid glands  in the neck and the  adrenal glands  just above each  kidney  in the abdomen. In many communities, they are the only surgeon trained to do this. In communities that have a number of subspecialists, other subspecialty surgeons may assume responsibility for these procedures.


Responsible for all aspects of pre-operative, operative, and post-operative care of abdominal organ transplant patients.  Transplanted organs include liver, kidney, pancreas, and more rarely small bowel.


Surgical oncologist refers to a general surgical oncologist (a specialty of a general surgeon), but thoracic surgical oncologists, gynecologist and so forth can all be considered surgeons who specialize in treating cancer patients.  The importance of training surgeons who sub-specialize in cancer surgery lies in evidence, supported by a number of clinical trials, that outcomes in surgical cancer care are positively associated to surgeon volume (i.e., the more cancer cases a surgeon treats, the more proficient he or she becomes, and his or her patients experience improved survival rates as a result). This is another controversial point, but it is generally accepted, even as common sense, that a surgeon who performs a given operation more often, will achieve superior results when compared with a surgeon who rarely performs the same procedure. This is particularly true of complex cancer resections such as  pancreaticoduodenectomy  for pancreatic cancer, and  gastrectomy  with extended (D2) lymphadenectomy for gastric cancer. Surgical oncology is generally a 2-year fellowship following completion of a general surgery residency (5–7 years).


Most cardiothoracic surgeons in the U.S. (D.O. or M.D.) first complete a general surgery residency (typically 5–7 years), followed by a cardiothoracic surgery fellowship (typically 2–3 years). However, new programmes are currently offering cardiothoracic surgery as a residency (6–8 years).


Pediatric surgery is a subspecialty of general surgery. Pediatric surgeons do surgery on patients under age 18. Pediatric surgery is 5–7 years of residency and a 2-3 year fellowship.


In the 2000s,  minimally invasive surgery  became more prevalent. Considerable enthusiasm has been built around  robot-assisted surgery  (also known as  robotic surgery ), despite a lack of data suggesting it has significant benefits that justify its cost. [ 3 ]


In Canada, Australia, New Zealand, and the United States general surgery is a five to seven year  residency  and follows completion of  medical school , either  MD, MBBS, MBChB , or  DO  degrees. In Australia and New Zealand, a residency leads to eligibility for Fellowship of the  Royal Australasian College of Surgeons . In Canada, residency leads to eligibility for certification by and Fellowship of the  Royal College of Physicians and Surgeons of Canada , while in the United States, completion of a residency in general surgery leads to eligibility for board certification by the  American Board of Surgery  or the  American Osteopathic Board of Surgery  which is also required upon completion of training for a general surgeon to have operating privileges at most hospitals in the United States.


In the  United Kingdom , surgical trainees may apply to enter training after five years of medical school and two years of the  Foundation Programme . During the two year core surgical training programme ("phase 1"), doctors are required to sit the Membership of the  Royal College of Surgeons  (MRCS) examination. On award of the MRCS by one of the four surgical colleges, surgeons may hold the title ' Mister ' or ' Miss / Ms. / Mrs ' rather than doctor. This tradition dates back hundreds of years in the United Kingdom from when only physicians attended medical school and surgeons did not, but were rather associated with  barbers  in the  Barber Surgeon's  Guild. The tradition is also present in many  Commonwealth  countries including  New Zealand  and some states of  Australia . After completion of phase 1 training, trainees may apply for a nationally awarded Higher Surgical Training (HST) programme, which lasts six years and is now divided into two further phases (phases 2 and 3). Trainees are expected to declare a sub-specialty before the end of phase 2, and training during phase 3 focuses on that sub-specialty. Before the end of HST, the examination for  Fellowship of the Royal College of Surgeons  (FRCS) must be taken in general surgery plus the subspeciality. Upon completion of training, the surgeon will be eligible for entry on the  GMC  Specialist Register. They may then apply to work both in the  NHS  and independent sector as a consultant surgeon, although many trainees complete further fellowships. [ 4 ]  The implementation of the European Working Time Directive limited UK surgical residents to an average 48-hour working week. [ 5 ]


The term  abdominal surgery  broadly covers  surgical  procedures that involve opening the  abdomen  ( laparotomy ).  Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see  stomach ,  kidney ,  liver , etc.) Diseases affecting the abdominal cavity are dealt with generally under their own names.


The most common abdominal surgeries are described below.


Complications of abdominal surgery include, but are not limited to: