# Welcome The focus of this textbook is on technique in the execution of cardiac surgery. Technique, when it is explicitly taught, is often taught dogmatically, but represents unseen evolution.[^a]To have persisted, it must have had an advantage. If that advantage can be understood, it can be communicated, and can be compared to alternatives.[^d] The operation is a sequence of techniques performed in the proper order. The sequence is a technique in and of itself. Different circumstances will make it advantageous to alter that sequence. Understanding the sequence favored by one surgeon facilitates learning the entirely different sequence preferred by another. It gives a framework for comparison.[^b] As much of what is contained herein is a matter of personal preference, I would like to keep things personal.[^c] My intention is to build out the components of outlines I have created for some common index procedures in cardiac surgery. The modularity of this approach will facilitate the construction of these outlines. Sternotomy, for example, does not typically vary all that much from the traditional bypass grafting to the traditional mitral (leaving aside, for the moment, the minimally invasive approaches). The modularity will hopefully permit exploration of alternative approaches: the aortic valve replacement performed by one surgeon may have a portion done differently, and therefore, more than one module will exist for that portion. The modularity will permit evolution. The routines of cardioplegia will be different for traditional blood cardioplegia to Del Nido. Readers may wish to provide criticism or describe alternative methods. Where appropriate, their editorial comments can be incorporated. Readers may request clarification verbally, or in the form of additional diagrams, and the modules will be improved. As time goes by, I may have the opportunity to supplement descriptions and diagrams with movies or pictures of procedures. As time goes by, "preference cards" and descriptions of preferred equipment and tools will be incorporated into the website. This platform uses the Obsidian note environment, which harnesses the power of "linked thinking" and digital publication. Readers are encouraged to explore this new paradigm of knowledge management. It will reward their attention. R. Anthony Perez-Tamayo, MD, PhD Editor, Author Technical Outlines in Cardiac Surgery Professor Department of Thoracic and Cardiovascular Surgery Loyola University Health System Section Chief Division of Cardiothoracic Surgery Hines Veterans Administration Hospital ## Contents - [[150 General Surgical Prinicples]] - [[200 A Coronary Anastomosis Primer]] - This is an informal exploration of a variety of concepts related to technique in bypass grafting. It is a good place to start exploring the website. - ### Outlines - The following are under construction at very preliminary stages - [[300 Technical Outline of Coronary Artery Bypass Grafting]] - [[400 Technical Outline of Aortic Valve Replacement]] - [[405 Notes on the Yang Procedure for Root Enlargement]] - [[420 Cabrol Skirt Graft for Aortic Root Replacement]] - [[450 Technical Outline of Transcatheter Aortic Valve Replacement]] - [[500 Technical Outline of Mitral Valve Replacement]] - [[600 Technical Outline of Mitral Valve Repair]] - [[650 Closed Biatrial Maze Procedure]] - [[700 Technical Outline of Repair of Aortic Dissection]] - [[800 Chest Tube Thoracostomy vs. Pigtail Catheters]] - [[900 Management Techniques]] - [[Hypotension Algorithm for Use in Post-operative Cardiac Surgery Patients]] - ### [[999 List of Contributors]] <a href="//www.dmca.com/Protection/Status.aspx?ID=fa072195-c704-437f-9dfb-fecf36ca941f" title="DMCA.com Protection Status" class="dmca-badge"> <img src ="https://images.dmca.com/Badges/dmca_protected_sml_120m.png?ID=fa072195-c704-437f-9dfb-fecf36ca941f" alt="DMCA.com Protection Status" /></a> <script src="https://images.dmca.com/Badges/DMCABadgeHelper.min.js"> </script> [^a]:Wisdom in common sayings, holes dug by generations of ants. - Charles Baudelaire [^d]:Much of this structure is built on technical points taught to me from sources from Duke to Loyola, and a little from my own ideas and observations. The largest contiguous mass of techniques comes to me from one of the most brilliant and inspiring surgeons I have ever had the privilege to assist, Mark Stout. The elegance and simplicity of his technique is matched only by his generosity in instruction. When the subject of technical brilliance is mentioned, it would be wrong not to reference Dr. Bakhos of Loyola, but that gentleman's success has a component of God-given ability and intuition that cannot hope to be captured and transmitted in a written document. [^b]:When I was a resident at Duke, Dave Peterseim, a resident senior to me, amongst his many kindnesses, handed me a photocopy of protocol that had been handed down for over a decade since it had been prepared by the distinguished graduate of the program, Randy Chitwood when he was a resident himself. It provided an extremely detailed description of a coronary artery bypass grafting procedure, done the "Duke" way. Even when I came to learn alternative methods, the document remained invaluable, and I handed it down to several of my trainees, who would photocopy it, and return the original. My very talented protege, Lourens Willekes, unfortunately lost my original. If anybody still has a copy, please send it to me. I'd love to include it amongst the outlines here. [^c]:A few years back, I discussed the idea for this book with my brother Parth Amin. As is typical for this remarkable individual, he instantly produced content, which goes to some of the foundations of [[300 Technical Outline of Coronary Artery Bypass Grafting]]. Moreover, he took some of our other ideas and ran with them, ultimately pitching them to the Thoracic Surgery Residents Association. This became the TSRA Decision Algorithms in Cardiothoracic Surgery textbook. This reminds me of an anecdote. I had this chemistry textbook in college that I particularly enjoyed because of its clear style, friendly margins, and overall layout. The margins often had what are known as glosses, little summaries of the material written in the central text. In an area discussing the Hall Process, the text mentioned that Charles Hall had invented the aluminum smelting process while still a graduate student, when his professor said during a lecture that anyone who could invent such a process would not only be a benefactor to the world, but would also be able to lay up for himself a great fortune. The gloss for this section read, "Some graduate students are more useful than others." So are some cardiothoracic surgery residents.