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Behavioral therapy includes proper toilet training order cialis professional online pills erectile dysfunction treatment thailand, after feeds cialis professional 40mg on line erectile dysfunction protocol pdf download free, three times daily for 5–10 minutes buy cialis professional no prescription impotence yeast infection. One word, one disimpaction person, one year, one stool/day, one sitting posture policy Oral is ideal. Guidelines for Functional constipation Hirschsprung disease maintenance dose of commonly used drugs are given in Table 9. More common Less common Meconium history—normal Delayed passage follow-up schedule Onset beyond infancy From birth • monthly follow up till regular bowel movement is Fecal soiling Spurious diarrhea achieved: Check diary, physical and rectal examination. Stool softeners like sorbitol containing difficulty and delay in passing dry stools. Children with refractory constipation with recurrent • Management includes drugs, diet modification, toilet impaction, not responding to routine use of laxatives, training and regular follow up and behavioral therapy. Clinical Practice Guidelines: Evaluation and Treatment manometry or ileo-colonoscopy, planning work for spinal of Constipation in Children. It has an incidence of 1/4,000–7,000 live births and an overall Currently, nearly 90% is diagnosed in the neonatal period or 4:1 male preponderance. Failure to pass meconium within 48 hours of occurs sporadically in full-term births, the rest accounts for birth is a cardinal clinical feature seen in 80–90% infants with the rare genetic/familial/syndromic forms. Symptoms of abdominal distension, poor embryology, etiopathogenesis and feeding, non-bilious vomiting and progressive constipation are characteristic. Infantile constipation often manifests Pathophysiology at weaning, and the recurrent symptom complex of the ganglion cells originate in the neural crest and migrate constipation—spurious diarrhea—abdominal distension— aborally along the bowel till the proximal anal canal; further failure to thrive during childhood. These parasympathetic toxic fulminant sepsis occurring at any age, even after ganglion cells of the intrinsic enteric nervous system definitive management is completed. It presents with fever, employ nitric oxide as the neurotransmitter and modulate foul smelling diarrhea, abdominal distension and lethargy; smooth muscle excitatory/inhibitory interactions in the some progressing to perforation of the cecum or appendix, bowel to effect a relaxation during rest and a coordinated particularly in the neonate. Such long segment disease is characterized by relative female preponderance and association with familial, syndromic and genetic forms. In conclusion, the contrast enema is a good screening conditions that may mimic it in the neonatal period. Historical clues and clinical features help to biopsy is essential to confirm the diagnosis of all forms resolve the issue and direct the confirmatory investigations. A suction fecal loading of rectum and perianal soiling, poor dietary fiber, evidence of associated voiding disturbances and psychological overlay. Though it is least invasive and attractive and has 75–95% accuracy, it is not widely available and difficult in the young uncooperative child. The mixed barium-stool picture in the delayed contrast enema film at 24 hours is also reliable. In associated colitis, double contrast enemas show a saw tooth mucosal contour and irregular uncoordinated contractions of the aganglionic segment. Note the question mark microcolon of total colonic aganglionosis in both rectal biopsy is also available. At laparotomy/laparoscopy, apposition of the distal most ganglionic bowel within a the gross transition zone, where evident, guides the siting centimeter of the dentate line, thus partially dividing the of more proximal leveling biopsies. Generally, an initial stoma is preferred in the histological features seen in the aganglionic poor risk malnourished patients, massively dilated proximal (absence of ganglion cells and hypertrophic nerve bundles bowel, emergency surgery, (enterocolitis, bowel perforation in described locations), ganglionic (regularly distributed or peritonitis) or non-availability of intraoperative histo- normal morphology ganglion cells along the entire logical leveling. However variable expressivity, incomplete sex disease, early management with standard protocols dependent penetrance have limited attempts at prenatal outlined above yields an excellent outcome. Symptomatology, pathophysiology, diagnostic work-up, and treatment of Hirschsprung disease in infancy and childhood. Yet only in abdominal pain; the most medical cause being constipation, a small number of children is the pain caused by organic and the most common surgical cause being appendicitis. The differential diagnosis of abdominal pain in children the traditional definition of recurrent abdominal pain used varies with age, sex, genetic and environmental factors. Hence the diagnostic term chronic abdominal pain which refers to pain present approach to abdominal pain in children relies heavily on continuously or occurring on a weekly basis for a minimum the history provided by the parent and child to direct a period of 2 months. It is a description, not a diagnosis, and stepwise approach to investigation rather than multiple can be due to organic disease or functional causes. A child with chronic abdominal pain poses a formidable challenge as the parents may be terribly worried; child etiology may be distressed and the practitioner may be concerned about ordering multiple tests to avoid missing occult Table 9. History the pelvic examination may suggest gynecologic prob- lems, such as endometriosis, ectopic pregnancy or ovarian • the location of the pain is important and the child may cysts or torsion. The red flag signs of organic disease include indicate the location of the pain by pointing with one localized tenderness in right upper or lower quadrants, finger or with the whole hand. Apley’s observation that localized fullness or palpable mass, hepatomegaly, spleno- “the further the pain from the umbilicus, the greater the megaly, costovertebral angle tenderness or perianal abnor- likelihood of organic disease” has held up reasonably malities. Carbohydrate breath testing for lactose intolerance is esophagitis and tricyclic antidepressants may cause indicated if empiric dietary interventions are inconclusive. Mesenteric lymph nodes should be considered as assessed through questions about school attendance, significant only when they are more than 10 mm in size. The physician should percuss the liver span, Barium Studies document the spleen and kidney size and determine the Barium swallow is not a sensitive test for gastroesophageal influence of leg motion (psoas sign). A barium contrast of the UgI tract should be performed with gentle and deep pressure as well may be useful to rule out malrotation especially if episodes as with rebound. Abdominal and rectal examinations will identify consti- Barium enema is indicated primarily in the context of 547 pation, perianal inflammatory lesions of Crohn’s disease, obstruction or chronic intussusception. There is increasing evidence that visceral hyperalgesia endoscopy (decreased threshold of pain to changes in intraluminal Upper endoscopy is rarely indicated as a first-line investiga- pressure) has been triggered by mucosal inflammation tion. Biopsies of the the pathophysiology of adult functional disorders esophagus, gastric antrum and duodenum may be indi- such as irritable bowel syndrome has been extensively cated even in the absence of macroscopic disease to iden- studied. Immune, neuronal and genetic factors have been tify microscopic diagnostic features of reflux esophagitis, studied. The management of functional abdominal pain begins with empiric intervention the acknowledgment that the pain is real, that extensive the child’s response to empiric intervention is also part of investigations are not warranted. This may include: in simple understandable language is an important part • Addition of a fiber supplement to rule out constipation of treating a child with functional abdominal pain such • A trial of H blocker in children with gerD or peptic ulcer as likening the abdominal pain to a headache and giving 2 disease prior to confirmatory investigations examples of hyperalgesia like a healing scar. It is important to identify, clarify and reverse possible Once a clear cut diagnosis is established specific treatment of the organic condition is indicated (further elaboration is physical and psychological stress factors that may out of scope of this chapter). Dietary interventions that have been tried with variable benefit include increasing dietary fiber intake. Psychological approaches including cognitive behavior- functional abdominal Pain al therapy and gut-directed hypnotherapy are increasingly Functional abdominal pain is uncommon under 5 years being used with success in children with functional abdomi- nal pain. The typical presentation is a child aged 5–10 years of age with vague, peri-umbilical pain which can be quite drug Therapy severe, interrupt normal activities and be associated Drug therapy for pain-related functional gastrointestinal with nausea, pallor and headache. The pain occurs during daytime and is unrelated alleviation rather than at precise pathophysiological to food intake, activity levels or stool pattern.

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The notions of personhood and person-centered care are central to the provision of competent and holistic palliative and end-of-life care buy cialis professional erectile dysfunction papaverine injection. Cassell highlights the wholeness of personhood order genuine cialis professional online erectile dysfunction with diabetes type 1, writing that “the understanding of the place of person during human illness requires a rejection of the historical dualism of mind and body” [6] best order cialis professional impotence with prostate cancer. A smaller red circle represents their disease process, and patients are asked, “Where would you put the illness disk to represent its place in your life right now? This correlates inversely with suffering and positively with perceived control over illness and coping resources. The questions include: Faith, belief, and meaning Importance and influence Community Address/action in care This tool can allow providers to open the door to further exploration and discussion around spiritual and existential distress and coping mechanisms. This is particularly important given the acknowledgment, as outlined before, that increased sense of religiosity may impact preferences related to end- of-life care, and the fact that addressing spiritual and existential suffering improves quality of life even at the end of life [1]. Critical and palliative care teams commonly utilize an interdisciplinary approach involving psychologists and social workers to help address the emotional distress of patients. A similar model of interdisciplinary collaboration is needed to most effectively—and efficiently—meet the needs of our patients who experience spiritual suffering [37]. This distinction should be recognized by clinicians to understand the nature of the relationship between patient and chaplain before hospitalization as well as the chaplain’s familiarity with serious illness and the health care system: 1. The hospital or health-system–based chaplain (health care chaplain) is most often employed by the hospital. They are often called to support patients and families whether or not they self- identify as religious or spiritual. Just as with physicians, there is a tacit agreement to abide by a specific code of ethics and professional practice standards. These chaplains work closely with clinical teams, are integrated with the spiritual and faith communities of the patients they serve, and often collaborate with denominational chaplains (see the following paragraph). The denominational chaplain is usually employed by a specific faith- based group, providing outreach to members of their religious community. These chaplains are not mandated to have the formal clinical training of their health care–based colleagues and can have a widely variable level of familiarity with critical illness and supporting those in medical crisis [38]. M is a 20 year-old young woman in a motor vehicle crash who sustained a severe traumatic brain injury and multiple fractures. Due to the extent and nature of her injuries, the neurology consult service has communicated to the family that they do not think she will have any meaningful neurologic recovery, though she is not brain dead. Her parents and two siblings have been involved in multiple family conferences over the course of her hospitalization. They identify as evangelical Christians and have been well supported by their church community during this time. They express a wish to continue life- sustaining treatments including mechanical intubation, and pressors indefinitely, stating that they have been praying for a miracle, and that Ms. The chaplain first met with the family separately as well to explore their theology and their conceptualization of how a miracle might occur. Through these conversations, they came to feel that God would intervene with a miracle if He chose, independent of the artificial means of life support that were being provided by the medical team. While the physician, nurse and social worker can assess and provide basic spiritual support for critically ill patients and their families, collaboration with chaplains, especially health care chaplains, is considered a best practice to address the spiritual needs of both patients and families [39]. Offering chaplaincy support to patients and families of critically ill patients earlier in their hospital stay may help address patient and family anxiety (see Box 36. Hope not only has a role in life when looking forward to a bright or ambitious future, but also plays a critical role for helping people cope with and reframe serious life events, such as trauma, illness, and even death [40]. Redirection of what to hope for and supporting a means of hope may strengthen patient–clinician bonds and prevent feelings of abandonment [36]. When fighting a life-threatening illness, maintaining hope can help patients and families foster emotional resilience. Clinicians often hesitate to share prognostic information with patients and family members for fear of depriving them of hope. Research indicates that physicians avoid prognostication for fear of (1) causing anxiety and increased stress for patients and families, perhaps worsening their clinical outcomes; (2) influencing colleagues’ attitudes about their effectiveness of care, potentially decreasing vigilance in the fight to cure; and (3) naming a possible negative outcome could make it more possible [41,42]. In contrast, many patients and families report that honest discussion about prognosis does not interfere with hope, and perhaps even helps support its maintenance. Despite this preference, family members of critically ill patients often demonstrate avoidant behaviors that suggest not wishing to “know all. This difficulty can be mitigated by frequent clinician conversations to help patients and surrogate decision-makers process and prepare for the worst, while continuing to hold on to hope for the best realistically possible outcome [43,44] (e. Often, while the initial reflexive response is to survive or to return to good health, when examined further, the answers are more complex. Physicians often believe that when patients and their families ask whether something more can be done, they are referring to whether another procedure or intervention is possible. However, patients are often asking whether more can be done to help restore their personhood—some improvement in their physical well-being, an increased ability to return to performing in their identified roles, or simply to return home without suffering. They are also often asking for clarity in prognosis and support for themselves and their families to complete their life story with respect for the way they have always lived [45]. Life review and dignity therapy are psychotherapy methods specifically for patients with life-limiting illness. Harvey Chochinov to address sources of psychosocial and existential distress as well as provide a means of recording in a written legacy or “generativity document” thoughts they find valuable for their loved ones. The interview technique focuses on the events, roles, and accomplishments that were most important to the patient over their lifetime and also allows the dying person to share their hopes and dreams for those they will leave behind [46]. The meaning making that is created through dignity therapy has been shown to decrease patient suffering and increase a sense of both dignity and purpose [47]. This can be a consequence not only of death itself, but also the loss of what constitutes the “personhood” of someone loved. For example, after 55 years of marriage, a wife can grieve the loss of her independent spouse who now needs to be placed in nursing home after a traumatic fall. A young athlete can grieve the loss of his sense of future and identity after having suffered a spinal cord injury. Resiliency can come from connection with sense of purpose, reflection on meaning of the relationship and life review, and both spiritual and religious factors. Respecting and infusing religious traditions and values at the end of life can further help add meaning to the loss. In many religions, ensuring a patient’s honor and integrity at the end of life can support a family’s bereavement. In Islamic tradition, for example, these efforts can reflect a family’s acceptance of the Koranic teaching that there are times to let nature take its course (Al-Qur’an 39:42) and an assurance that their advocacy role as loving family members has been fulfilled [48]. Historically, a “bereavement exclusion” was made in the diagnosis of major depressive disorder—reflecting a belief that bereavement is a natural process and should not be pathologized. While it shares some symptomatology with major depression, grief has unique features as well, including the preservation of self-esteem, and positive memories and feelings related to the loved one combined with sadness. Perceived conflict between medical decisions and religious beliefs may contribute to increased suffering during bereavement [52,53].

Prophylactic Use of Antibiotics Certain clinical situations purchase cialis professional now erectile dysfunction pump surgery, such as dental procedures and surgeries discount cialis professional 20 mg without prescription erectile dysfunction treatment kolkata, require the use of antibiotics for the prevention rather than for the treatment of infections (ure 28 cheap generic cialis professional uk icd 9 code erectile dysfunction due diabetes. Because the indiscriminate use of antimicrobial agents can result in bacterial resistance and superinfection, prophylactic use is restricted to clinical situations in which the benefits outweigh the potential risks. The duration of prophylaxis should be closely controlled to prevent the unnecessary development of antibiotic resistance. Complications of Antibiotic Therapy Even though antibiotics are selectively toxic to an invading organism, the host may still experience adverse effects. For example, the drug may produce an allergic response or may be toxic in ways unrelated to the antimicrobial activity. Hypersensitivity Hypersensitivity or immune reactions to antimicrobial drugs or their metabolic products frequently occur. For example, the penicillins, despite their almost absolute selective microbial toxicity, can cause serious hypersensitivity problems, ranging from urticaria (hives) to anaphylactic shock. Some reactions may be related to the rate of infusion, such as “Red man syndrome” seen with rapid infusion of vancomycin. Patients with a documented history of Stevens-Johnson syndrome or toxic epidermal necrolysis reaction (a severe sloughing of skin and mucus membranes) to an antibiotic should never be rechallenged, not even for antibiotic desensitization. Direct toxicity High serum levels of certain antibiotics may cause toxicity by directly affecting cellular processes in the host. For example, aminoglycosides can cause ototoxicity by interfering with membrane function in the auditory hair cells. Chloramphenicol can have a direct toxic effect on mitochondria, leading to bone marrow suppression. Fluoroquinolones can have effects on cartilage and tendons, and tetracyclines have direct effects on bones. Superinfections Drug therapy, particularly with broad-spectrum antimicrobials or combinations of agents, can lead to alterations of the normal microbial flora of the upper respiratory, oral, intestinal, and genitourinary tracts, permitting the overgrowth of opportunistic organisms, especially fungi or resistant bacteria. These infections usually require secondary treatments using specific anti-infective agents. Sites of Antimicrobial Action Antimicrobial drugs can be classified in a number of ways: 1) by their chemical structure (for example, β-lactams or aminoglycosides), 2) by their mechanism of action (for example, cell wall synthesis inhibitors), or 3) by their activity against particular types of organisms (for example, bacteria, fungi, or viruses). Chapters 29 through 31 are organized by the mechanisms of action of the drug (ure 28. Doxycycline (a tetracycline) should be avoided due to the potential harm to the fetus. Nitrofurantoin, amoxicillin (a penicillin), and cephalexin (a cephalosporin) are generally considered safe. Isoniazid is only active against Mycobacterium tuberculosis, while ceftriaxone, ciprofloxacin, and imipenem are considered broad spectrum due to their activity against multiple types of bacteria and increased risk for contributing to the development of a superinfection. Clindamycin, linezolid, and vancomycin exhibit time-dependent killing, while daptomycin works best when administered in a fashion that optimizes concentration-dependent killing. Aminoglycosides, including gentamicin, possess a long postantibiotic effect, especially when given as a high dose every 24 hours. Which of the following antibiotics requires close monitoring and dosing adjustment in this patient given his liver disease? Erythromycin is metabolized by the liver and should be used with caution in patients with hepatic impairment. Chloramphenicol and sulfonamides (sulfamethoxazole) can cause toxic effects in newborns due to poorly developed renal and hepatic elimination processes. Tetracycline can have effects on bone growth and development and should be avoided in newborns and young children. Although the minimum inhibitory concentration impacts the effectiveness of the drug against a given bacteria, it does not affect the ability of a drug to penetrate into the brain. Lipid solubility, protein binding, and molecular weight all determine the likelihood of a drug to penetrate the blood–brain barrier and concentrate in the brain. Stevens-Johnson syndrome is a severe idiosyncratic reaction that can be life threatening, and these patients should never be rechallenged with the offending agent. Itching/rash is a commonly reported reaction in patients receiving penicillins but is not life threatening. A patient may be rechallenged if the benefits outweigh the risk (for example, pregnant patient with syphilis) or the patient could be exposed through a desensitization procedure. This is not an allergic reaction, and the patient can be rechallenged; however, the patient might be at risk for developing C. Overview Some antimicrobial drugs selectively interfere with synthesis of the bacterial cell wall—a structure that mammalian cells do not possess. The cell wall is composed of a polymer called peptidoglycan that consists of glycan units joined to each other by peptide cross-links. To be maximally effective, inhibitors of cell wall synthesis require actively proliferating microorganisms. Penicillins the basic structure of penicillins consists of a core four-membered β-lactam ring, which is attached to a thiazolidine ring and an R side chain. Members of this family differ from one another in the R substituent attached to the 6- aminopenicillanic acid residue (ure 29. The nature of this side chain affects the antimicrobial spectrum, stability to stomach acid, cross-hypersensitivity, and susceptibility to bacterial degradative enzymes (β-lactamases). Mechanism of action Penicillins interfere with the last step of bacterial cell wall synthesis, which is the cross-linking of adjacent peptidoglycan strands by a process known as transpeptidation. For this reason, penicillins are regarded as bactericidal and work in a time-dependent fashion. In general, gram-positive microorganisms have cell walls that are easily traversed by penicillins, and, therefore, in the absence of resistance, they are susceptible to these drugs. Gram-negative microorganisms have an outer lipopolysaccharide membrane surrounding the cell wall that presents a barrier to the water-soluble penicillins. However, gram-negative bacteria have proteins inserted in the lipopolysaccharide layer that act as water-filled channels (called porins) to permit transmembrane entry. Natural penicillins Penicillin G and penicillin V are obtained from fermentations of the fungus Penicillium chrysogenum. The potency of penicillin G is five to ten times greater than that of penicillin V against both Neisseria spp. Most streptococci are very sensitive to penicillin G, but penicillin-resistant viridans streptococci and Streptococcus pneumoniae isolates are emerging. The vast majority of Staphylococcus aureus (greater than 90%) are now penicillinase producing and therefore resistant to penicillin G. Despite widespread use and increasing resistance in many types of bacteria, penicillin remains the drug of choice for the treatment of gas gangrene (Clostridium perfringens) and syphilis (Treponema pallidum). Penicillin V, only available in oral formulation, has a spectrum similar to that of penicillin G, but it is not used for treatment of severe infections because of its limited oral absorption. Penicillin V is more acid stable than is penicillin G and is the oral agent employed in the treatment of less severe infections. Addition of R groups extends the gram-negative antimicrobial activity of aminopenicillins to include Haemophilus influenzae, Escherichia coli, and Proteus mirabilis (ure 29.

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Attachment of the Chords to the Mitral Leaflets A double-armed purchase cialis professional 20 mg without prescription impotence psychological, 5-0 Prolene suture is used to shorten each elongated chord buy cialis professional 40mg with visa erectile dysfunction jelqing. Both needles are then passed upward through the leaflet buy generic cialis professional 40 mg on line erectile dysfunction doctors mcallen texas, very close to one another, and tied snugly on the atrial side. This draws up the excess length of chord underneath the leaflet and pulls it down to the level of the plane of the mitral valve to reestablish apposition with the other leaflet. The chordal-shortening sutures may injure or tear an otherwise normal leaflet, thereby interfering with a satisfactory repair and culminating in leaflet tear. In adults, we have adopted the simpler technique of using Gore-Tex artificial chords (see subsequent text). Ischemic Mitral Regurgitation Ischemic mitral valve prolapse may occur following myocardial infarction secondary to injury with elongation or partial or complete rupture of a papillary muscle. Incomplete detachment of a single head may be amenable to repair with chordal replacement or transfer and/or resection of a portion of the affected leaflet as described in preceding text. Most patients with ischemic mitral disease have functional regurgitation due to annular and left ventricular dilation and/or displacement of the papillary muscles. Mitral valve replacement may be the best option in patients with severe ischemic mitral regurgitation who are undergoing coronary revascularization. In patients with moderate ischemic mitral regurgitation and heart failure symptoms, or dilated annulus, or nonviable lateral myocardium, mitral valve repair with an annuloplasty ring may be a good option. Most surgeons use an undersized complete ring annuloplasty in these patients along with revascularization of all ischemic, viable myocardium. However, when reparative procedures do not appear to provide a durable successful outcome, mitral valve replacement should be considered. In recent years, experimental and clinical studies have established the importance of the subvalvular apparatus in retaining the normal geometry of the left ventricle and its function. Therefore, whenever the mitral valve has to be replaced, every attempt should be made to preserve the native subvalvular apparatus or replace native chordal structures with Gore-Tex sutures to maintain the mitral annular-papillary muscle continuity. If the anterior leaflet is not extensively diseased, an ellipse of tissue is excised and the rim of the leaflet tissue containing primary chords is reattached to the anterior annulus using pledgeted mattress sutures to be used subsequently for valve implantation. If the leaflet is thickened or calcified, it is divided into two to four segments, depending on the size of the valvular leaflet. These buttons are reattached to the anterior annulus with the valve sutures in an anatomic manner (s. The posterior leaflet, when pliable, can usually be retained completely together with the attached chordae tendineae. Redundant leaflet tissue is folded up into the annulus by placing the valve sutures through the annulus and bringing them through the leading edge of the leaflet tissue. Alternatively, incisions or small wedge resections of leaflet tissue between the chordal attachments are performed if the posterior leaflet is thickened and fibrotic to allow implantation of a larger valve. At times, the mitral valve leaflet and the subvalvular apparatus are grossly diseased and calcified and must be totally resected. The diseased leaflets are then pulled and stretched slightly with a heavy suture or forceps to bring their annular attachments into view. A traction suture in the annulus adjacent to the posteromedial commissure allows better exposure and provides countertraction for the complete removal of the diseased valve. Excessive Leaflet Excision A good margin of leaflet tissue should always be left with the annulus to allow secure attachment of sutures for subsequent placement of a prosthesis. Overzealous excision of leaflets may leave a weakened annulus, making valve replacement insecure or even resulting in detachment of the left atrium from the left ventricle. Papillary Muscle Excision Only the calcified and diseased chords should be excised, leaving the fibrous tips of the papillary muscles untouched. Removal of an excessive amount of papillary muscle may weaken the ventricular wall, which may result in hematoma within the wall and possible rupture (see subsequent text). Excessive Pull on Papillary Muscle During the process of leaflet excision, the valve tissue should never be pulled overzealously. The heart arrested with cardioplegia is flaccid, and any excessive pull on the papillary muscle may tear a buttonhole defect through the weakened left ventricular wall. If such a catastrophe occurs, it must be detected immediately and repaired with pledgeted mattress sutures. The posterior descending coronary artery is likely to be in close proximity to this type of ventricular wall tear. Precautions must therefore be taken to avoid occluding the coronary artery in the process of repairing the defect. Pledgeted, double-armed, atraumatic sutures are passed deeply, well away from the coronary artery, and tied snugly over another pledget. If bleeding continues after the application of several well-placed sutures, the whole area of the defect should be covered with a patch of P. A: Diseased leaflets are pulled and stretched with Allis forceps or heavy suture to expose their annular attachments. C: A traction suture in the annulus adjacent to the posteromedial commissure allows better exposure and provides countertraction for the complete removal of the diseased valve. Annular Calcification the mural annulus of the mitral valve may become infiltrated with heavily calcified tissue that may extend into and involve the full thickness of the atrioventricular groove and wall. Consistency of the surrounding tissues and the location of the circumflex coronary artery in the atrioventricular groove make any attempt to repair this defect most hazardous. Atrioventricular Groove Disruption Overzealous removal of calcium from the posterior annulus of the mitral valve or forcibly implanting too large a prosthesis may result in disruption of the atrioventricular groove. This catastrophe is often noted as the patient is being weaned off cardiopulmonary bypass when the operative field is flooded with bright red blood. A large patch of autologous pericardium treated with glutaraldehyde or bovine pericardium is cut to the appropriate size and shape. It is sewn in place, well away from the margin of the defect, to the left ventricular wall, left atrial wall, and left atrioventricular junction. A smaller mitral prosthesis is reimplanted in the usual manner except that it is attached to the pericardium P. The hollow cavity in the annulus formed during removal should be irrigated and closed with pledgeted sutures. Injury to Posterior Left Atrium Overzealous removal of organized and/or calcified blood clots from the left atrial wall during mitral valve surgery or a maze procedure may result in a shear injury and serious bleeding. It is always safer to go back on cardiopulmonary bypass and repair the bleeding site from within the left atrium. This may be tedious but the experienced surgeon will not be tempted to repair any bleeding from the back of the heart following mitral valve surgery by displacing the heart upward, no matter how minor the bleeding site may appear to be. Technique for Chord Replacement All the native chordal structures are resected if the subvalvular apparatus is markedly diseased, as in patients with rheumatic disease in whom there is fusion of the chordae tendineae, foreshortening of the chordal apparatus, and papillary muscle thickening. Continuity between the mitral annulus and the papillary muscle is then recreated with 4-0 Gore-Tex sutures to produce artificial chordae tendineae that extend from the heads of the papillary muscle to the annulus. If there is no fibrous tissue, the suture is buttressed with a small, soft felt or pericardial pledget and the suture is tied snugly or locked on itself.

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