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By B. Georg. DeVry University.

Khan A et al (2009) A prospective buy discount sildenafil 100mg on-line, randomized discount 100mg sildenafil with amex, crossover undergoing coronary artery bypass grafting-A double pilot study of inhaled nitric oxide versus inhaled blind randomized study cheap sildenafil 100mg free shipping. J Thorac Cardiovasc Surg 138:1417–1424 implantation of the Jarvik 2000 left ventricular assist 54. Awad H, Abd El Dayem M, Heard J et al (2010) Initial Cardiovasc Drug Rev 23:71–98 experience with of-pump left ventricular assist device 44. Not all kinds of thrombus (wide wall questions remain to be answered immediately adhesion) require therapy, but have to be exactly before implantation. In pressure, determination of shunting volume at addition, exclusion of thrombus in the lef this time does not support decision making. Using the long axis aortic view (midesophageal, 120°) in color Doppler modus, the width of the regurgitant jet (1 cm below its origin) relative to the width of the lef ventricular outfow tract is. Terefore, parameters support post-procedural pharma- additional monitoring of lef atrial pressure is cological therapy guiding. Empirical knowledge myocardial contractility (epinephrine, milrinone) identifes a right to lef atrial pressure diference of and additional reduction of pulmonary vascular more than 8 mmHg or lef atrial pressure near zero resistance (inhaled nitric oxide, iloprost). Eur Heart J Cardiovasc Imaging 16:233–270 imaging modalities in patients with left ventricular 6. Kukucka M, Stepanenko A, Potapov E, Krabatsch T, Clinical management of continuous-fow left Redlin M, Mladenow A, Kuppe H, Hetzer R, Habazettl H ventricular assist devices in advanced heart failure. Right-to-left ventricular end-diastolic diameter ratio J Heart Lung Transplant 29:S1–39 and prediction of right ventricular failure with 3. J Heart ventricular failure after lvad implantation: Prevention Lung Transplant 30:64–69 and treatment. Cardiol Clin 30:291–302 (2013) Increased right-to-left ventricle diameter ratio 5. Unfortunately, there is limited litera- 8 h as continuous infusion, may be suggested. Te clinical correlate of this the patient, the issues of the planned surgery, and self-amplifying cascade is a rapid decrease of the the experience of the team involved with the use of platelet count, which in some patients is associated such strategies. In spaces where there is no fow and blood stagnation and therapeutic bivalirudin Bivalirudin, a short-acting (elimination half-life concentrations cannot be maintained by approximately 25 min) direct thrombin inhibitor, is continuous systemic infusion, “clot formation” the only agent which has been prospectively studied will occur. However, and fushed grafs, cannulas, or the chamber of the bonded bivalirudin molecule is cleaved by fushed devices. Terefore, cardiotomy suction thrombin itself, so that the thrombin molecule should be replaced by cell salvage and fow in achieves its anticoagulant action again. While reservoirs maintained by using shunting lines and approximately 80% of the elimination of bivalirudin continuous stirring of the volume. Te Apart from its potential benefcial role on strong systemic vasodilatory efect of iloprost outcomes, this approach obviates for any may induce or further increase vasoplegia and preoperative diagnostic procedure in case thus require the administration of high dosages thrombocytopenia ensues and allows for safe of potent vasoconstrictors. Additionally, specifc laboratory assays performed, to confrm we recommend waiting for approx. In patients without preoperative transfused to adequately replace the coagulation antiplatelet therapy and clinical signs of factors. Federmann M, Dragomer D, Grant S, Reemtsen B, References Biniwale R (2014) Use of bivalirudin for anticoagulation during implantation of total artifcial heart. Haneya A, Philipp A, Puehler T, Ried M, Hilker M, Zink W Corpor Technol 46:170–172 et al (2012) Ventricular assist device implantation in 10. Hillebrand J, Sindermann J, Schmidt C, Mesters R, therapy for cardiac surgery: an update. Anesthesiology Martens S, Scherer M Implantation of left ventricular 123:214–221 assist device under extracorporeal life support in 3. Greinacher A (2015) Heparin-induced thrombocy Geroulanos S, Karabinis A et al (2015) Perioperative topenia. Am antithrombotic therapy and prevention of thrombosis, 9th J Hematol 90:608–617 ed: American College of Chest Physicians Evidence-Based 13. Schenk S, El-Banayosy A, Prohaska W, Arusoglu L, Anticoagulation for critically ill cardiac surgery Morshuis M, Koester-Eiserfunke W et al (2006) Heparin- patients: is primary bivalirudin the next step? Koster A, Huebler S, Potapov E, Meyer O, Jurmann M, (2012) Argatroban anticoagulation for heparin Weng Y et al (2007) Impact of heparin-induced induced thrombocytopenia in patients with thrombocytopenia on outcome in patients with ventricular assist devices. Morshuis M, Boergermann J, Gummert J, Koster A anticoagulation with bivalirudin for patients with (2013) A modifed technique for implantation of the implantable ventricular assist devices. Artif Organs HeartWare™ left ventricular assist device when using 38(4):342–346 211 19 Intraoperative Right Ventricular Failure Management Matteo Attisani, Paolo Centofanti, and Mauro Rinaldi 19. Sometimes Cardiopulmonary bypass is routinely esta- hemodilution can be completely avoided using blished between right atrium and ascending aorta. In case of concomitant surgery on the tricuspid In this case priming fuid is completely removed valve, mitral valve, or interatrial septum, bicaval by flling the circuit in a retrograde fashion with cannulation is mandatory. No activate clotting time control is It is very important to check the adequacy of needed. During a second rapid ventricular pacing, Implantation: Impact the pump is rapidly inserted. Te most common locations for air elevation and shaking of lef ventricular apex is embolism are the right coronary artery and the almost impossible. Te lef ventricular vent Te ascending aortic vent should remain open has to be clamped and removed just afer the until all visible air is removed. Te treatment consists of further 215 19 Intraoperative Right Ventricular Failure Management de-airing, an adequate coronary perfusion 19. Levosimendan Pump speed should be maintained as low as also plays a debated role in this crucial phase. Te pump Ventilation should be started as soon as fow is not exactly the cardiac output which is possible afer de-airing to decrease pulmonary infuenced by the combination of the device fow vascular resistances. It plays an active role during the systolic PaO2/FiO2 fraction >200 shortening of the free wall-septum dimension of Low positive end expiratory pressure the ventricle, the so-called bellow action [26]. J Cardiothorac implantation seems to have a protective efect on Vasc Anesth 19:406–408 the right ventricle, and it is encouraged in selected 12. Tinglef J et al (1995) Intraoperative echocardiographic patients with a signifcant preoperative risk of study of air embolism during cardiac operations. Best considered as option in order to avoid future Pract Res Clin Anaesthesiol 26:217–229 re-sternotomy in bridge-to-transplant patients. Holdy K et al (2005) Nutrition assessment and Efcacy and advantages of this technique in management of left ventricular assist device patients. One of the main Transplant 18:346–350 limitations of this approach is the difcult access 16. It is not indicated in case of already planned hemodynamic subsets to respirator settings.

After the superior aspect of the is undertaken discount sildenafil 100mg free shipping, aided by the visualization of intrathecal fuo- tumor is removed buy genuine sildenafil on line, the arachnoid and normal pituitary fall rescein (Fig sildenafil 75 mg fast delivery. Recently we have begun also placing an additional na- nal fat and fll but do not overpack the sella. The foor of the soseptal fap56 on top of the gasket seal, although the neces- sella is then reconstructed with vomeric bone or Medpor sity of this last step is unknown. If there has been a large opening in the skull placed over the closure to obtain a watertight closure. The base, such as a transplanum, transtuberculum approach, latter substance is preferred. Then a piece of vomeric bone, the is so small and patients often go home soon after surgery. This draws the tissue graft the patient has poor wound healing from diabetes, smoking, steroid use, prior radiation therapy, or renal failure, then a drain is often placed at the beginning of the operation. This is left open for only approximately 24 hours, and drainage is kept at a minimum (approximately 5 mL/h). I Postoperative Care All patients except those without Cushing’s disease are given a single dose of dexamethasone (2 mg) the night after sur- gery and the following morning. Levels less than 2 ng/mL correlate In addition to the smaller controlled studies, several larger with a high likelihood of long-term remission. Early postoperative imaging is often misleading at distinguishing residual tumor from postoperative changes. I Conclusion However, after normal postoperative changes are accounted for, nodular enhancement within the sella can be an indica- The continued development of pituitary surgery has relied tion of residual tumor. The endoscope and the endonasal, en- enhancement that can represent secretions, blood, packing, doscopic, transsphenoidal approach is one such advance that or residual tumor adherent to the surrounding arachnoid or has brought about a minimally invasive technique to remove brain that prevents collapse of the cavity. At this point, postoperative for other lesions, depending on the exact anatomical loca- blood and secretions should have resolved. We tions regarding residual disease include observation, repeat advocate a team approach that comprises both an otolaryn- surgery, radiosurgery, or fractionated radiotherapy. The otolaryngologist, experi- plete resection is observed, radiographic follow-up is recom- enced in endoscopic sinus surgery, provides crucial expertise mended with repeat imaging at 6 months postoperatively in navigating normal and abnormal sinus anatomy during and then annually. For patients with hormone-secreting the procedure, whereas the neurosurgeon trained in pitu- tumors, biochemical follow-up should be conducted for itary surgery brings the know-how to safely resect pituitary recurrence. We continue to use intraop- erative navigation but have shifted away from simple fuo- roscopy to more detailed frameless stereotactic navigation. I Endoscope Versus Microscope Lastly, a thorough knowledge of the hypothalamic-pituitary Several studies have attempted to directly compare the en- axis is necessary to manage these patients successfully in the donasal, endoscopic approach with the traditional, micro- perioperative period. When investigators able endocrinologist is helpful, the operating surgeon must compared a cohort of endonasal, endoscopically treated pa- acquire the independent comprehension of perioperative tients with a control group of patients treated with the tradi- endocrinologic issues to care for patients appropriately in tional approach, it was shown that the endonasal, endoscopic situations when specialized assistance is not available. Endoscopic, endonasal extended 1096 transsphenoidal, transplanum transtuberculum approach for resec- 2. Endoscopic endonasal approaches to the cavern- pituitary adenomas: general principles and indications in non- ous sinus: surgical approaches. Extended endoscopic endonasal transsphe- tumors with televised radiofuoroscopic control. J Neurosurg noidal approaches to the suprasellar region, planum sphenoidale 1965;23:612–619 and clivus. Laryngoscope 1992;102:198– tuitary surgery with intraoperative magnetic resonance imaging. Endoscopic endonasal E9 transsphenoidal approach: outcome analysis of 100 consecutive pro- 29. Minim Invasive Neurosurg 2002;45:193–200 neurostereoendoscopy: subjective and objective comparison to 2D. Endoscopic endonasal trans- Minim Invasive Neurosurg 2009;52:25–31 sphenoidal surgery. The role of the endoscope 2009;64(5, Suppl 2):288–293, discussion 294–295 in the transsphenoidal management of cystic lesions of the sellar re- 31. Neurosurg Rev 2008;31:55–64, discussion 64 dimensional endoscopic sinus surgery: feasibility and technical 14. San Diego: Plural Publishing; dal pituitary surgery via the endoscopic technique: results in 35 2007:89–104 consecutive patients with Cushing’s disease. Medical and surgical management of mi- endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 2005;102:189– son of techniques for transsphenoidal pituitary surgery. Transsphenoidal endoscopic approach in the treatment of Rathke’s sphenoidal microsurgery versus the sublabial approach for the treat- cleft cyst. Neurosurgery 2005;56:124–128, discussion 129 ment of pituitary tumors: endonasal complications. Surgery 1999;109:1838–1840 for Rathke cleft cysts: technical considerations and outcomes. Childs Nerv Syst 2005;21:696–700 technique after endoscopic expanded endonasal approaches: vascu- 40. Laryngoscope 2006;116:1882–1886 of transsphenoidal surgery in the treatment of craniopharyngiomas. Evaluation of the J Neurosurg 2004;100:445–451 hypothalamic-pituitary-adrenal axis immediately after pituitary 41. En- sphenoidal microsurgical treatment of Cushing disease: postopera- doscopic cranial base surgery: classifcation of operative approaches. Clinical review: the strategy of im- 2005;83:45–51 mediate reoperation for transsphenoidal surgery for Cushing’s dis- 44. J Clin Endocrinol Metab 2005;90:5478–5482 growth hormone pituitary adenomas with long-acting somatosta- 60. J Clin Endocrinol Metab 2000; uation of patients with acromegaly: clinical signifcance and timing 85:1287–1289 of oral glucose tolerance testing and measurement of (free) insu- 46. Results of lin-like growth factor I, acid-labile subunit, and growth hormone- stereotactic radiosurgery in patients with hormone-producing pitu- binding protein levels. J Clin Endocrinol Metab 2005;90:6480– itary adenomas: factors associated with endocrine normalization. In: de Divitiis E, rum prolactin levels measured immediately after transsphenoidal Cappabianca P, eds. Comparison of endonasal endoscopic surgery and tumor resection in patients receiving no steroids post-operatively. Surg Neurol 2002;58: Endocrinol Invest 2005;28:502–508 371–375, discussion 375–376 50.