Technique for Supravalvular Pulmonary Artery Stenosis

Technique for Supravalvular Pulmonary Artery Stenosis A novel beating-heart technique for supravalvular pulmonary artery stenosis INTRODUCTION: Pulmonary artery stenosis (PAS) may be congenital or acquired and presents itself as isolated or multiple lesions. Acquired PAS generally occurs following the surgical correction of congenital cardiac malformations such as anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) and tetralogy of Fallot (TOF). Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery. In this report, our objective is to present a new surgical technique without the need for cardiopulmonary bypass used for a patient undergoing surgery for ALCAPA who required re-operation on the first postoperative day due to supravalvular pulmonary stenosis. CASE REPORT: In a 8-year old boy, direct re-implantation of the left coronary artery into the aortic root was accomplished through median sternotomy under cardiopulmonary bypass. The general status of patient declined with accompanying signs and symptoms of right-sided heart failure within the first six postoperative hours. Also, liver enzyme levels were elevated and renal functions deteriorated. A biochemical profile revealed serum glutamic-oxaloacetic transaminase (SGOT) 832 mU/dl, serum glutamic-pyruvic transaminase (SGPT) 789 mU/dl, serum urea 65 mg/dl, and creatinine 2.1 mg/dl. Echocardiography showed severe right ventricular dysfunction and mild pulmonary insufficiency. As well as the supravalvular gradient was 80 mmHg, there was no transvalvular pressure gradient. Since supravalvular PAS was the suspected cause of the clinical instability of the patient, an urgent surgery was planned. SURGICAL TECHNIQUE A median sternotomy was used for the surgical procedure. Pump was not used to avoid the possible adverse consequences of cardiopulmonary bypass in this patient with a poor general status and impaired renal and liver functions. Firstly, an incision line on the stenotic supravalvular pulmonary artery segment was drawn. Then the dimensions of the graft to be placed were determined visually and the graft was prepared. The oval-shaped graft was sutured on the target stenotic pulmonary artery segment using 6/0 polypropylene sutures. During this procedure, special emphasis was placed on two issues: 1. Other than the proximal edge of the graft (the right ventricular side) all other edges were sutured using continuous sutures. However, no knots were tied and both ends of the suture were left free. 2. During the placing of the grafts, a space was created to form a convex structure in-between the anterior surface of the pulmonary artery. Then, a small linear incision on the pulmonary artery was made distally on the pulmonary artery using a scalpel inserted from the proximal opening of the graft. Simultaneous pressure on the incision site was exerted digitally to prevent bleeding. The incision was propagated longitudinally using a Metzenbaum scissor. Upon exposure of the pulmonary artery, the convex structure disappeared spontaneously by eliminating the distance between the graft and the anterior surface of the pulmonary artery. Soon after the incision was made in the distal direction on the pulmonary artery according to a pre-determined length, the sutures on the proximal surface of the graft were stretched as to fix the graft on the pulmonary artery. At the end of the procedure, while a moderate level of tension was maintained on the sutures manually, the proximal end of the graft was closed using continuous sutures. Thus, at the end of the procedure the desired pulmonary artery diameter was achieved. No hemodynamic instability was observed during the procedure. Intraoperative echocardiography showed no residual gradients on the pulmonary artery. The patient was extubated at postoperative 12th hour. A quick clinical improvement of right-sided heart failure was observed during the follow-up along with restoration of normal liver enzyme levels within 48 hours and normal renal functions within one week after surgery. The patient was discharged at postoperative 8th day. Follow-up examination at 1 year after surgery showed a good general status with weight gain. No gradient was detected at the pulmonary artery by echocardiography. DISCUSSION: PAS may be congenital or acquired. Acquired pulmonary artery stenosis is generally a complication of the surgical procedures performed for the repair of complex congenital cardiac malformations (1). For instance, in patients such as ours with ALCAPA, supravalvular PAS may develop following surgery (2). In certain circumstances, both congenital and acquired types of pulmonary artery stenosis may pose significant surgical challenges. Particularly, the presence of clinical instability may severely limit the therapeutic options in newborns. Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery. In recent years, despite significant advances in the technology of stent and balloon production, surgical repair remains an important therapeutic option. The success rates with balloon dilatation in these patients are limited (3). On the other hand, intravascular stents are associated with the formation of re-stenosis in the long term due to somatic growth (4). Thus, surgical repair stands out as an important alternative to both other approaches in pulmonary stenosis. We didn’t prefer catheterization because of early period after surgery and impaired kidney function. The current surgical methods for the reconstruction of the PAS may be associated with untoward consequences due to the need for cardiopulmonary bypass. Therefore, in order to avoid possible adverse effects of cardiopulmonary bypass, we developed a novel surgical technique to be used for the repair of supravalvular pulmonary artery stenosis without pump. The surgical technique utilized in this patient is simple and safe distinguishing itself from other techniques by negating the need for pump. Particularly, it seems suitable for selected, clinically unstable cases who may be adversely affected by cardiopulmonary bypass. In previously operated patients with supravalvular pulmonary artery stenosis, this technique may be safely applied without the increased risk of bleeding or thromboembolic events. However, larger patient populations are warranted to more firmly establish its safety. Nevertheless, we believe that this technique for the pulmonary artery reconstruction may provide significant increases in the diameter of the pulmonary artery in a beating heart with minimal morbidity and mortality. According to our knowledge, there have not been reported any off-pump technique for PAS in the English literature to date. In conclusion, this newly developed method of supravalvular PAS surgery is safe and long lasting. This surgical technique may be applied on patients not only who had an isolated supravalvular PAS but also who were previously operated, developed restenosis in early period and were under risk if pump was used without disrupting the hemodynamic stability.

Taking a Stand

Jessica Pratt Taking a Stand Dear ladies and gentlemen of the court, today I stand before you to debate whether or not Atticus should have defended Tom Robinson. I assure you that you can place all of your trust in me because I am completely unbiased since I am not racist and I am in no way related to Atticus. While it is true that Atticus Finch caused dissension by defending a black man, he had no choice but to defend Tom Robinson, a man created in the image of God and therefore equal to his fellow white and black brothers. Today, the prosecutors will point out some facts about Atticus that even I, his defender, cannot deny.I cannot in good conscience begin to defend Atticus until I acknowledge his weaknesses. To begin with, the truth remains that Atticus put his family and himself in emotional and physical danger. Because Atticus chooses to defend Tom Robinson, Scouts classmates pick on her at school. For instance, Cecil Jacobs says, â€Å"My folks said your daddy was a disgrace a n’ that n***** oughta hang from the water-tank. † (Lee 102). He also called Scout a coward when she refuses to fight him. In addition, Atticus places himself in physical danger by defending Tom Robinson when a mob threatens him because he camped out at Tom’s jail cell (202).If Jem and Scout would not have stepped in, injuries and maybe death could have occurred. No doubt, Atticus put his family and himself in emotional and physical danger. Furthermore, the prosecutors will argue that Atticus should not have defended Tom Robinson since he knew he would lose. Atticus tells Scout that he will not win this case since Tom Robinson is a black man accused by a white family (101). A black man is considered dishonest and the chance of the jury to believe a black man’s word versus a white family was extremely unlikely.As I stated earlier, no one can deny these facts or the logic behind the reasons. Not even I can. However, in spite of these facts, I ask that you con sider the reasons why Atticus puts his family and himself in physical and emotional danger. When you hear these, I believe you will see his actions as justifiable and acquit him of any guilt. Although Atticus loves his family and would never want harm to come to them, if he did not defend Tom Robinson he could be considered a hypocrite. Instead, Atticus continues with his job and defends Tom Robinson the best he can (218).For instance, most of the town is upset with Atticus since he is defending Tom Robinson. One townsman said, â€Å"But Atticus aims to defend him. That’s what I don’t like about it. † (218) Most importantly, Atticus should have defended Tom Robinson because he knew it was the right thing to do. He knew deep down in his heart that Tom was innocent. Therefore, he deserved to be defended as if he were white. On the contrary, if Atticus did not defend Tom Robinson, he would be portraying himself as a racist. Just like all of the others in Maycomb wh o are just as bad as a supposed Negro is.Secondly, and perhaps most importantly, Atticus defended Tom Robinson for his kids. He needed to set a good example for Jem and Scout so that they would not become racist like most of the residents of Maycomb County. Atticus feels that he couldn’t hold up his head in town, and he couldn’t represent Maycomb County in the legislature if he did not defend Tom Robinson (100). Atticus believed he would be viewed as another racist if he didn’t take this case. When Atticus is explaining this to Scout he says, â€Å"I couldn’t even tell you or Jem not to do something again. (100) Therefore, if Atticus did not defend Tom Robinson, he would not be a good example for his kids and they could turn into another prejudice resident in Maycomb County. Dear Ladies and gentleman of the court, today I stand before you pleading with you that you realize that the only thing Atticus Finch is guilty of is defending an innocent man. He ha d no choice but to defend Tom Robinson, a man created in the image of God and therefore equal to his fellow white brothers and black brothers. If Atticus didn’t defend this man, who would?Would anybody else have the courage, integrity, and moral character to come forward and defend him? Most likely no other man would defend Tom Robinson in the way he deserved to be defended. If Atticus did not defend Tom Robinson, than an innocent man would be hauled away to jail for a crime he did not commit. Furthermore, if Atticus would not have defended Tom Robinson, then Tom would not have a chance to go back to the normal life he once had. Tom has to provide for his family, he can’t accomplish this if he is stuck in prison. He still has a loving wife, joyful children, and caring friends who need Tom in Their lives.Not only will Tom Robinson be crushed, but the many hearts of others will be crushed also. In addition, Atticus is a lawyer because he wants to represent his country by defending the defenseless. Atticus is proud of his country and in America, all men are created equal despite their race. Since we are all created equal, every man deserves the right to a fair trial. By defending Tom Robinson, Atticus is portraying the love that he feels for his country. Therefore, Atticus did the right thing and followed his heart. Works Cited Lee, Harper. To Kill a Mockingbird. Grand Central Publishing, New York; 1960.

Unanswered Issues With Topics to Do an Argumentative Essay on Exposed

Unanswered Issues With Topics to Do an Argumentative Essay on Exposed Topics to Do an Argumentative Essay on for Dummies Estimate the background of your audience, to ensure that you supply them with all essential facts so that they could comprehend all particular features of the subject. You will then have to approach this issue by gathering, generating, and evaluating credible sources to back up your evidence. Basically, you merely restate all the former information in summary form. When there is information in essay, it's by-the-by, and if there's an opinion, an individual need not trust it for the future. One of the most vital elements of an argument essay is to ponder and present either side of the problem and undertake a comprehensive evaluation of each. Argumentative essays utilize logic, facts, and reasoning to specify the victor. A superior argumentative essay clearly presents either side of the argument. Despite the popular myth, it is more than simply trying to p rove your point with a few arguments. Topics to Do an Argumentative Essay on at a Glance Before writing an argumentative essay, there's one important thing you should know. Knowing the question you're answering is the most significant portion of AP writing. The matter here is that it takes so many parts of paper to write just a single textbook. The Characteristics of Topics to Do an Argumentative Essay on If you can't determine what the question is, return and reread the prompt. You've got to dig deep into the problem. When choosing an issue to argue, you have to select a topic that has more than 1 side. To compose an effective argumentative essay, you need to find a topic that you want to know more about and one that offers two sides of a problem instead of giving an absolute answer. HOW TO DRAFT YOUR THESIS STATEMENT In order to compose a sound thesis, it's first essential to take into account the topic for a question. It's crucially important to totally engage yourself in this issue you will write. Your topic ought to have the potential to provide you enough arguments for your essay. It must be interesting to you. This kind of essay requires a good framework and great support. You might also want to incorporate a quick discussion of more research which should be completed in light of your work. The last area of the introduction to your argumentative essay ought to be your thesis statement. Tie every claim you make to a bit of evidence to make sure the very best essay possible. Facts, Fiction and Topics to Do an Argumentative Essay on The art of argumentation is not a simple skill to acquire. There are many unique tactics to approach an argumentative essay. Writing an argumentative essay is a skill that anyone in school should know, although it can be useful outside the classroom, also. While both argumentative and persuasive essays share the identical aim of convincing the opponent in the rightfulness of your perspective, they use various approaches to attain that goal. As an example, in college, you might be requested to compose a paper from the opposing viewpoint. Make sure to spell out why you pick a concrete standpoint and why do you feel the other one is not quite as excellent as the one that you opt for. Or you might use an intriguing quote or startling statistic. The first thing you're likely to have to do is to choose a topic that has more than one clear side. Type of Topics to Do an Argumentative Essay on An argumentative essay is among the many academic essay types. Lastly, be certain your argumentative essay has no grammar and punctuation mistakes. Every argumentative essay should depend on a topic that may be debated. The only means to writing a captivating argumentative essay is to realize the structure in order to remain focused and make a strong point.

Essay on The Importance of Olivia in Twelfth Night

The Importance of Olivia in Twelfth Night nbsp; nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp; Olivia, in Twelfth Night, is the character who unifies the play by her involvement in each of the three plots.nbsp; Olivia is loved by Orsino, but she loves Cesario.nbsp; Olivia plays a vital role in the plot to gull Malvolio, although she is unaware of it.nbsp; Olivia also has an active role in the plot to dupe Sir Andrew because he is jealous of her attention towards Cesario. In conlusion Olivia is the one who inifies the play the best. nbsp; nbsp;nbsp;nbsp;nbsp;nbsp; Olivia is involved the the love plot more then any other plot in which she is involved in.nbsp; Olivia is loved by others, and she is also in†¦show more content†¦nbsp; Olivia also explains how she is in love with Cesario by telling him that she loves him in front of him in his face when he is over at Olivias house. nbsp; nbsp; nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp; I love thee so that, maugre all thy pride nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp; (Act 3, Scene 1, Line 149). nbsp; Cessario also knows that Olivias in love with him, because he realizes that after Malvolio had given the ring to Cessario apon returning from Olivias house.nbsp; This is prooven to us when Cessario is on the stage him self reading a soliloquy, which read: nbsp; nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp; She loves me sure; the sunning of her passion invites me in this churlish messenger nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp;nbsp; (Act 2, Scene 2, Lines 19-20). nbsp; The last person that Olivias in love with is Sebastian.nbsp; This is the person which Olivia is fooled by.nbsp;Show MoreRelatedWilliam Shakespeare s Twelfth Night1130 Words   |  5 Pagesfascinating. Specifically, the love that is elucidated through the characters in Twelfth Night is passionate, but unfortunately it is not always accepted by the desired character. Viola relays Orsino’s love for Olivia with devotion and warmth but sadly, the love is still refused by Olivia (1.5.244-245). Shakespeare writes about love with such importance and ecstasy, loves presence in Shakespeare s works, highlighted in Twelfth Night is comparable to fertile tears, thunder and fire. Love is variable, it isRead MoreRole Of Female Characters In Twelfth Night1608 Words   |  7 PagesIn William Shakespeare’s Twelfth Night, the female characters have a strong constitution specifically Olivia and Viola. The play begins with a shipwrecked Viola who decides to disguise herself and go under the assumed name of Cesario. Viola Cesario falls in love with Duke Orsino who is in love with Olivia. The Duke asks for Cesario to woo Olivia for him however Olivia begins to fall for Cesario. Later, Violas twin brother reappears, and Olivia mistakes him for Cesario proposes to him. In theRead MoreMisinterpretations Of Love In Twelfth Night By William Shakespeare1021 Words   |  5 Pages Twelfth Night Behind the Mask Love can not hide behind a mask forever in the end truth will prevail. In the play Twelfth Night written by William Shakespeare there are many circumstances where there are misinterpretations of love in various romantic relationships. There are many instances where characters where used disguises were used to create plot development. In Shakespeare play trickery was used to create plot development. Mistaken identity was used to create a complicated love triangle. ShakespeareRead MoreThemes Of Social Mobility Through Marriage1655 Words   |  7 PagesThis paper critically analyses the theme of social mobility through marriage in Shakespeare’s play ‘Twelfth Night’. 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Shakespeare, in his play Twelfth Night uses the Romantic comedy genre and its conventions of strong themes of love and a series of obstacles and misunderstandings concluded with a harmonious union of the loversRead MoreWilliam Shakespeare s Twelfth Night Essay1329 Words   |  6 Pagesplay Twelfth Night shows us the harmful effects of superficiality and self-love. Many of the characters in the play have these two bad qualities and suffer a great deal because of them. In this paper, I will be analyzing how the suffering in the play is caused by the characters’ superficiality and self-love. I will begin by examining the superficiality and self –love of the society in the play. Then I will look at how this superficiality is manifested through the characters of Orsino, Olivia, andRead MoreThe Twelfth Night, By Oscar Wilde1158 Words   |  5 Pagesimmediate needs for the family. However, William Shakespeare’s Olivia, in the Twelfth Night, and Oscar Wilde’s Gwendolen, in the comedy, The Importance of Being Earnest narrative seemingly contradict orthodox gender norms. Olivia and Gwendolen both live in a social constru ct based on male dominance. Yet both of them upends this norm and play dominant role in both of their relationships. In his play the Twelfth Night, Shakespeare uses Lady Olivia to illustrate the complexities of love and courtship byRead MoreThe Importance of Madness as a Theme in Twelfth Night by William Shakespeare629 Words   |  3 PagesThe Importance of Madness as a Theme in Twelfth Night by William Shakespeare Madness is a very important theme that is present in the whole course of the play Twelfth Night. Firstly, we have Malvolio almost turning mad because of the cruel joke the other servants play on him. They make him think he is mad and they also make Olivia think he is mad because of the funny way in which he is acting. There is also the theme of mad love. Some examples of this are Orsino being madlyRead MoreWilliam Shakespeare s Twelfth Night1133 Words   |  5 PagesThe Power of Words and Realities†¨ †¨ The Twelfth Night was a religious festival held during the Elizabethan Era. It also †¨Ã¢â‚¬ ¨celebrated the concept of the reversal of normal order, where the lower and upper class had the †¨Ã¢â‚¬ ¨chance to experience each other’s roles in society. It was a day of celebration in which enabled a †¨Ã¢â‚¬ ¨time of foolishness for each class. This religious festival seem to have influenced Shakespeare’s †¨Ã¢â‚¬ ¨play, Twelfth Night in relations to the concept of the foolishness celebration ofRead MoreThe Fool Or Jester, Hired By Olivia858 Words   |  4 PagesFeste is presented as the fool or jester, hired by Olivia to entertain as an allowed fool. Feste can speak however he likes to anyone and everyone, including a well respected person such as Olivia. It seems that he almost reverses the roles. He talks down to people that have higher â€Å"ranks† than he. At one point, Feste says to Olivia â€Å"Do you not hear fellows? Take away the lady,† making everyone else seem as they are the fool. Feste is actually quite clever and witty, though it may not seem