During an extended-follow-up of up to 15 years, VA patients had similar survival rates between an initial strategy of PCI plus medical therapy and medical therapy alone in patients with stable ischemic heart disease. In an article, published in the NEJM of 11/12/2015, 

In the COURAGE trial, the authors compared an initial management strategy of optimal medical therapy alone with optimal medical therapy plus PCI among patients with stable ischemic heart disease and found no significant difference between the treatment groups with respect to the composite primary end point of death from any cause or nonfatal myocardial infarction or with respect to any of the other cardiac end points (including death from any cause or hospitalization for acute coronary syndrome) during a median follow-up period of 4.6 years.

Surgical competence requires a complex set of interdependent roles and abilities that include psychomotor, cognitive, and interpersonal abilities.[i]

A shift in surgical procedures towards minimally invasive techniques has greatly complicated surgical education with a major potential impact on emergency patient care.

Introduction

This summer a former resident of mine – now an older surgeon himself – asked me whether I’d be interested in re-activating my surgical career (not a simple thing to do). As explanation, he mentioned a critical shortage of experienced surgeons in traditional surgical techniques, as present day’s education is now mainly focused on minimally invasive procedures. During the past ten years this has become a major issue, particularly in trauma and emergency surgery, where often “open” procedures are necessary.

2010 Lectures Tufts University School of Medicine including:

 

Content of the Thorax:

  • Mediastinum, 
  • Lungs
  • Chest wall

Case studies involving the thorax, mediastinum, embryology of the heart & circulatory systems

Anatomic and clinical reviews that will include basic symptoms and findings, diagnosis & treatment

Tufts University school of Medicine

Clinical Anatomy

Joan F. Tryzelaar, M.D., F.A.C.S, F.A.C.C.P.

 January, 2011

Before we go on to congenital heart problems, it is good to review how to get into the chest:

Clinical Case:

You have just been invited to participate in an operation. The surgeon plans a posterolateral thoracotomy to enter the chest.  He will tell you that he plans entry via the 6th intercostals interspace(Pearl: found two finger widths below the tip of the scapula).

As shown in SYNTAX and other studies, CABG is associated with significantly lower rates of death, myocardial infarction (MI) and target vessel revascularization (TVR) vs. PCI.

A new study by the American Heart Association has shown that although the majority of clinical CardioVascular Disease (specifically Coronary Artery Disease and Stroke) events occur at middle and older ages, atherosclerosis begins in childhood and cardiovascular health among adolescents aged 12 to 19 years  is alarmingly poor. 

Cardiovascular health in adolescent males by race/ethnicity (aged 12–19 years):

 

In determining a treatment strategy for a patient with CAD, there are a variety of considerations that need to be made when selecting the appropriate treatment:

In 1995 Topol[1] first described what vascular surgeons have known for many years:

The pressure drop in a fluid flowing through a long cylindrical pipe such as a stenotic artery becomes functionally significant when the obstruction exceeds 70%, first described in the Poiseuille law in 1846[2].

As was stated in Topol's paper: “Accordingly, before the residual stenosis in an infarct vessel is addressed, there should be demonstration of either spontaneous or provocable signs of ischemia… clinicians and investigators rely excessively on angiography for clinical decision-making… Procedures should not be performed solely to improve the luminal appearance—so-called coronary “cosmetology".

This principle was tested with the PCI Fractional Flow Reserve FAME 1[3]&2[4] trials: