PROCEDURES 56K | 300K

	CABG (Coronary Artery Bypass Graft Surgery)
	TMR (Transmyocardial Revascularization)
	VALVULAR SURGERY (Replacement or Repair)
	ADULT CONGENITAL HEART SURGERY
	CARDIAC TUMOR SURGERY
	PERICARDIAL SURGERY
	LUNG TUMOR SURGERY
	DIAGNOSTIC LUNG SURGERY
	SURGICAL TREATMENT OF LUNG INFECTIONS
	MEDIASTINAL DISEASE SURGERY
	SURGERY FOR CHEST WALL TUMORS

	CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) DEFINITION:
	Procedure by which blocked arteries, either totally or partially blocked, have a conduit (or tube) to reroute blood around the area (s) obstructed.
	ANATOMY:
	The heart is a complex structure made up of 4 chambers, 2 on the right side and 2 on the left. The 2 top chambers are called atrium (left and right). The 2 bottom chambers are called the ventricles (left and right). Blood coming from the body empties into the right atrium, from here the blood passes to the right ventricle and this muscular chamber contracts to send the blood to the lungs. In the lungs the blood is allowed to exchange carbon dioxide (lose it) and acquire oxygen. Now the blood with oxygen goes to the left side of the heart and is taken to the rest of the body .
	The heart muscle also has to receive blood to contract, and does this by way of the arteries around the heart (coronary arteries). It is these coronary arteries that can develop placking and lead to chest pressure or possible heart injury (heart attack). The heart has 2 major arteries: right coronary artery and left coronary artery. The right coronary artery supplies the right side of the heart and the inferior wall of the heart, actually providing part of the blood to the electrical system of the heart (conduction system). The left main coronary artery leads to 2 major branches going to the anterior and left lateral surfaces of the heart.
	REASON FOR BYPASS SURGERY:
	When the arteries around the heart that transport blood to the heart muscle develop blockages and patients develop chest pressure (angina), then bypass surgery is one of the ways to solve this problem. The common symptom of a blockage is chest pressure that may move to the arms, neck, jaw or base of teeth, but symptoms could also include: shortness of breath, nausea, sweating sensation or a dusky look to the skin. some patients may just feel slightly tired and decrease their level of regular activities. They may even feel too tired to perform basic daily activities such as bathing, grooming, and housework/cleaning.
	OTHER OPTIONS:
	Besides bypass operations, other things can be considered if one is not sure of surgery or is not a surgical candidate. One can consider heart medications, which are indicated when an operation is not possible or if an operation is not desired. There are times when the cardiologist can perform angioplasty (ptca: inflation of a balloon introduced through the groin to open the area blocked) and/or stenting (introducing through the groin a cage-like structure that expands to keep the area obstructed open) .
	ANESTHESIA FOR SURGERY:
	The cardiac anesthesiologist is a vital member of the heart surgery team. This type of doctor has done special training to place patients undergoing heart surgery to sleep in a comfortable and safe fashion . The cardiac anesthesiologist will sedate the patient before going into the operating room. Cardiac anesthesia is provided in a very smooth fashion in order not to stress an already diseased heart. After the patient is asleep a tube is placed by the cardiac anesthesiologist through the vocal cords into the windpipe, this allows a machine to breath for the patient (ventilator). After the operation the patient will usually wake-up with the tube in his/her windpipe, which will be removed as soon as the patient is able to breath on their own. The breathing tube is only kept in while necessary.
	INCISIONS: MINIMALLY INVASIVE OR STANDARD INCISION:
	The standard incision for bypass operations extends along the length of the breastbone (sternum). These incisions usually heal well with low risk of infection . There are times when small incisions (minimally invasive) can be made on the chest wall to perform bypass operations. this is indicated when one or maybe two arteries need to be bypassed. therefore, this can not be offered to everyone. These smaller incisions are usually performed next to the breastbone and tend to be more uncomfortable.
	SURGERY ON A BEATING HEART OR STILL HEART:
	The heart-lung machine (pump) was devised in the mid-50's and has been used very effectively to stop the heart and allow the blood to continue to be circulated to the rest of the body. While the heart-lung machine is working, the surgeons can perform delicate surgery on and inside the heart. After the work is completed, the heart is allowed to start beating again and take over it's normal function, use of the heart-lung machine, is then discontinued with new developments, surgery can now can be safely performed with the heart beating. this has come about because of the invention of devices that allow the heart to beat and only the area worked on to be still. This is attempted in most bypass operations, but some patients will not tolerate this and require the heart-lung machine for their operation. the major advantages of the beating heart surgery are: less swelling and weight gain, probably a shorter stay in the hospital, and less need for transfusions. Some of these patients may have a shorter recovery and may feel back to normal quicker.
	LENGTH OF SURGERY:
	Most bypass operations take between 3 to 5 hours, if everything proceeds on a standard basis. Remember, this is the actual operation, the patient may be taken from his/her room several hours earlier to prepare for surgery, after surgery there will be a period of time before the family can see the patient. Families are kept informed of progress during surgery and recovery .
	CONDUITS USED: VEINS AND/OR ARTERIES FOR BYPASSES:
	To reroute the blood around the areas obstructed, certain conduits (tubes) have to be used. For many years veins removed from the inside or back of the legs have been used. These have served patients well, but arteries work longer than veins . The arteries used are usually taken from inside of the chest wall, next to the sternum (internal mammary arteries). other arteries used come from the forearm (radial arteries), still other arteries used come from the abdomen( arteries that supply blood to the stomach) .
	RISK FACTORS: THESE ARE THE RISK FACTORS FOR CORONARY ARTERY DISEASE:
	AGE HIGH BLOOD PRESSURE MALE SEX DIABETES MELLITUS HIGH CHOLESTEROL OR TRIGLYCERIDES OVERWEIGHT SMOKING HISTORY STRESS FAMILY HISTORY OF CORONARY ARTERY DISEASE
	POSTOPERATIVE EXPECTATIONS:
	1. After surgery most patients will experience some degree of chest wall discomfort, usually treated with analgesics with good pain control. 2. It is not uncommon to experience a tired and weak sensation. This is transient and can be expected with any major surgical procedure. 3. after any surgical procedure it is common to experience loss of appetite, possibly nausea, and in some patients vomiting. all these are likely from anesthesia and the number of medications used. 4. Changes in mental status or "mood swings' can occur and are also usually transient. A patient may experience agitation, confusion, anxiety or even depression. Patients over the age of seventy are more prone to these mood changes, but this can affect anybody. 5. Weight gain from surgery is not uncommon and after surgery diuretics (medication to cause kidneys to eliminate water from the body) are given to the patient. Some patients may gain from five to fifteen pounds and sometimes even more
	LENGTH OF STAY IN THE HOSPITAL:
	Patients are taken to the cardiac intensive care unit after the operation, where most patients remain for a minimum of 48 hours. Patients may have to remain longer if other problems are being addressed. Subsequent to the intensive care unit, patients are transferred to a cardiac monitored ward, where the patient has more freedom for activity and for family visitation. Most patients stay here from three to four days before discharge. Therefore, a typical open-heart surgery hospital stay is five to seven days .
	TRANSMYOCARDIAL REVASCULARIZATION (TMR):
	This procedure has come into practice within the last ten years. It offers the patient who continues to have anginal symptoms, and has small or no vessels that can not be bypassed an option. Most of the patients considered candidates for "laser surgery" have had bypass operations before, and now come to the physician with angina. They have no vessels that can be bypassed again or vessels that are too small with a high likelihood of closing again. This is usually not performed on first time operations and is not for everybody .
	HOW TRANSMYOCARDIAL REVASCULARIZATION IS PERFORMED:
	In the operating room this procedure may be performed with the use of the heart-lung machine (the heart not contracting and not beating) or without (patient is under anesthesia, heart contracting) a handheld device emits the laser beam to create channels from the outside into the inner cavity of the heart. Postoperative bleeding is usually not found with this procedure. Channels are created in the areas that are ischemic (areas of the heart muscle not receiving blood and nutrients that they need) and the arteries are too small or have poor runoff (diffuse plaquing through the whole vessel and are likely to close). if scarring of the heart muscle is present, tmr is not indicated since that part of the heart is not viable.
	HOW TMR WORKS:
	Several explanations have been offered as to how channels on the heart improve symptoms. First, the channels created through the full thickness of the heart muscle may allow blood to move from the inside cavity of the heart into the muscle so that oxygen and nutrients can be taken out of the blood. Secondly, when the laser forms the channels, it causes a certain type of white blood cells to release communicating substances and call on other cells to create new blood vessels (angiogenesis). the laser may intercept nerve fibers that carry the sensation for chest pain (angina) and therefore improve the discomfort. Other reasons have been proposed but it is likely the reason tmr works is due to a combination of the above.
	EXPECTATIONS ON TMR:
	This does not make you live longer. The objective of this procedure is to improve the quality of life. Tmr has reduced the number of medications used, reduced readmission into the hospital for angina, and has actually improved in some patients their exercise capabilities. Foremost, it has been shown to reduce the frequency, and intensity of angina, and allowed patients to live more comfortably.
	HEART VALVE SURGERY:
	Anatomy of heart valves: the heart has four chambers, two on the left and two on the right. Between each chamber a valve (door guarding entrance into the next chamber) exists. On the left side of the heart the mitral valve is between the left atrium (chamber that receives blood from the lungs that is oxygenated) and the left ventricle (muscular chamber that contracts. Moving blood to other parts of the body). between the left ventricle and the aorta (major artery that delivers blood to other parts of the body) exists the aortic valve. On the right side of the heart exists the tricuspid valve (between the right atrium and right ventricle) and the pulmonary valve (between the right ventricle and the pulmonary artery). All of the valves have three leaflets ("TRAP DOORS") Except for the mitral valve which has two . Heart valves can be affected by a long list of diseases, which include congenital problems, rheumatic fever, infections, and coronary artery disease with it's potential problem of myocardial infarction. When the valves are injured from disease they are either replaced or repaired. Most commonly the aortic valve is replaced and for this we have several options to choose from. Depending on the patients age, the valve may be replaced with a mechanical valve (anticoagulation will be needed for the rest of that persons life) or a tissue valve (either a bovine or porcine valve, with need for anticoagulation for 6 weeks to 3 months). There are situations when a person less than 60 years of age, or has a contraindication to anticoagulation, or has endocarditis (infection affecting the heart valve or valves and other inner chambers of the heart), when a homograft (cadaveric valve) can be considered. Patients less than 35 years of age may be considered for a procedure called the "ROSS PROCEDURE". The ross procedure consists of transferring the patients pulmonic valve to the aortic position and replacing the pulmonary position with a homograft. The objective of the "ROSS PROCEDURE" Is to allow the pulmonary valve to grow with the patient and it has been shown to have long durability. Always be aware that whatever type of valve is used to replace the native aortic valve, it may not be permanent and may need further surgical interventions. Repair of aortic valve in most adults is rarely performed, there are situations where the valve can be repaired. In children the aortic valve is affected in a way where repairing is more feasible and all attempts to preserve the native valve are made. Depending on the reasons for mitral valve disease, repair or replacement are the options. well over 60% of the time the mitral valve can be repaired, these can be simple or complex repairs. When there is extensive deformity of the mitral valve or the repair is not possible, replacement should be carried out with either the mechanical or tissue valve substitutes. it has been documented in medical literature, that repairs of the mitral valve are usually long lasting, with improved long term survival for the patient. Mitral valve repairs require anticoagulation for approximately 3 months. Some experimental work is being performed for homografts to the mitral position, but this is only in the trial stages. It is not uncommon to have your cardiac surgeon and cardiologist ask for permission for an intraoperative transesophageal echocardiogram (tee) to verify the quality of the repair or replacement of a valve. the latter is performed while the patient is asleep. It consists of a probe through the mouth and down the esophagus (food tube that passes by the back of the heart) to view the heart chambers and valves. Tricuspid valve disease is usually caused by changes on the left side of the heart. We refer to this as a functional effect, that is, if the left side of the heart has a valve that is either leaking blood or not allowing blood to move in a forward direction, pressure builds up enlarging the chambers on the right side of the heart. If the tricuspid valve is affected in this way then we usually can repair the valve. At times the tricuspid valve is affected by other diseases (rheumatic fever, collagen vascular diseases, intravenous drug usage causing endocarditis, bacterial/viral/fungus endocarditis) that could cause the valve to leak or restrict the opening and closing of the valve. If there is no injury or scarring of the valve and have separation of the valve leaflets, then it can be repaired. if there is too much destruction or deformity of the valve then this is replaced with either a tissue valve (pig valve or cow heart lining) or mechanical valve. Pulmonary valve disease in adults is uncommon and usually found with either rheumatic fever patients or patients who have endocarditis. If this valve is affected and is leaking or the movement of the leaflets (trap doors that form the opening and closing mechanism of the valve, with the pulmonary valve there are 3 leaflets) is restricted, replacement is considered. the pulmonary valve may be replaced with a mechanical valve, tissue valve or homograft (cadaveric valve). Pulmonary valve abnormalities are more commonly found in pediatric heart patients. The pulmonary valve in pediatric patients can be narrowed or deformed and require repair or replacement with either a prosthetic valve or homograft.
	PRECAUTIONS/AWARENESS AFTER HEART VALVE SURGERY:
	Anticoagulation will dictate certain restrictions, such as avoiding heavy contact. patients must be aware of the possibility of extensive bleeding with minor injury. Patients are advised to wear risk bands indicating their consumption of an anticoagulant. You must advise any medical personnel of your use of an anticoagulant before being submitted to any surgery or invasive procedure (medical or dental). Also, with any medical or dental procedure antibiotic prophylaxis should be carried out. Have the physician/dentist providing care follow the American Heart Association antibiotic prophylaxis protocol. with any concern or questions consult your cardiologist or cardiac surgeon.
	ADULT CONGENITAL HEART SURGERY:
	Most congenital problems are found earlier in life especially if these are compromising to the heart and the growth and development of the individual. There is a percentage of adults that present with symptoms that might mitigate a work-up, others have no symptoms and the problems are found incidentally. Most commonly found problems consist of seattle defects (mostly atrial, i.e. Upper chambers of the heart). Ventricular septal defects are less common and are usually small. Even though these septal defects may be symptomatic (without symptoms), such abnormal connections between heart chambers should not be left alone. Abnormal connections can lead to congestive heart failure caused by the abnormal pressure that overloads the lower pressure chamber. Other conditions such as endocarditis (infection of the heart valves and/or inner chambers of the heart) can be experienced from the septal defects. When these defects exist, clots can potentially form in the legs or pelvis and migrate to the left side of the heart and embolize (clot or other material can travel to other parts) to the brain or other parts of the arterial circulation (paradoxical embolus). Most defects found in adults are simpler and easier to address than in children, and these should not be left unattended.
	PERICARDIAL SURGERY:
	Anatomy. the pericardium is the envelope that covers the heart. This is a tough membrane that can be affected by different diseases. The space between the surface of the heart and the pericardium contains approximately 30 ml of fluid. Certain diseases can cause an increase in fluid, large amounts of fluid can cause compression of the heart and decrease cardiac function. Other diseases can cause the pericardium to thicken or calcify and also compromise the function of the heart. The pericardium, surrounds all parts of the heart and a short portion of the major arteries and veins as they leave and enter the heart, respectively.
	DISEASES AFFECTING THE PERICARDIUM:
	1. Infections: virus, bacteria and fungus can affect the pericardium. these infections can lead to the thickening of the pericardium as well as production of fluid or pus. When tuberculosis affects the pericardium blood can collect in the pericardial envelope. Some infectious processes, such as tuberculosis can chronically lead to calcification of the pericardium, and hence affect blood return and expulsion out of the heart. 2. Tumors: malignancies in a different part of the body can lead to metastatic lesions causing fluid to accumulate and affect the function of the heart. Breast cancers are among the most common to cause this fluid accumulation. 3. Renal failure: when kidney function is affected, excess fluid can again accumulate around the heart and possibly affect function. 4. Collagen vascular diseases: less common diseases such as these can affect the pericardium in the same way as has been described above. examples include: scleroderma, rheumatoid arthritis, and systemic lupus erythomatosis 5. Idiopathic: there are many cases when fluid will accumulate and a specific cause will not be identified.
	REASONS FOR SURGERY OF THE PERICARDIUM:
	Surgery is performed to make a diagnosis and to treat/alleviate the problem caused. When fluid accumulates in the pericardial space, a piece or the entire pericardium is removed. The pericardial sac plus a sample of the fluid is submitted for analysis of the above possible causes. removing part or the entire pericardium relieves the pressure caused by the fluid or by a thickened pericardium. The surgical approach to the pericardium, is through the upper abdomen (underneath the tip of the breastbone), the left or right chest walls (either through a scope or by opening the lateral chest wall), or through the breastbone (especially if the entire pericardium is to be removed). Drains are usually left in place to remove any residual fluid. These are discontinued when the drainage decreases. If only a portion of the pericardium is removed to evacuate fluid, there is a chance fluid can reaccumulate and cause the same problem. If fluid reaccumulates after only a portion of the pericardium has been removed, the next option is to go through the breastbone and remove most of the pericardium.
	LUNG TUMOR SURGERY:
	Many different types of tumors can affect the lungs, most originating in the lungs, others moving via the blood from other parts of the body. Smoking, exposure to asbestos, and other chemicals or particles cause some of the tumors originating in the lung. Certain tumors can begin in areas of scarring without ever having smoked. So, it can not be said that smoking is the only cause of this devastating disease. the earlier the tumor is detected, the better the chance of surgical removal. There are certain tumors that even though small, could have moved to other parts of the body (metastasized). When a tumor is identified in the lung, the recommended procedure is to remove that segment of the lung (lobe). If the tumor is involving two adjacent lobes, then both should be removed, if the patient can tolerate this. If the tumor is involving the hilum (where the artery, veins and bronchial tubes come into the lung) then the entire lung may have to be removed. Before removing a piece of the lung or the entire lung, test are carried out to determine if this can be done. If the patient's lung function does not allow removal of the entire suggested lobe (s) then only a portion is removed. When a portion of the lung or the entire lung is removed, lymph nodes are sampled and sent for analysis to determine if the tumor has spread to these areas. Removing lymph nodes does not improve survival but helps in determining the stage of the tumor. Before removing a lobe or the entire lung (pneumonectomy), a tissue diagnosis has to be made. in other words, one must know if the tumor is present or not. An area of suspicion may be present and look like a tumor, but should not be removed without verification. Diagnosis of lung tumors can be made by several procedures: Something as simple as sputum samples can help identify a tumor, tissue acquired by having a scope place through the nose or mouth (bronchoscopy). lung biopsies performed by either opening the chest wall and acquiring a sample, or with a scope through the rib spaces (vats or thoracoscopy). there are times when the tumor can not be seen on the lung tissue and sampling of lymph nodes in the middle of the chest (mediastinoscopy) can provide an answer. If surgery can not be performed because of the advanced stage of the lung tumor or if during surgery the tumor can not be totally removed, then other forms of treatment have to be considered. If tumor has spread to the lymph nodes or other parts of the body then chemotherapy is offered to the patient. When the entire tumor can not be removed, radiation offers a reasonable option to reduce the chances of tumor reappearing where some was left. there are tumors that affect the lymph nodes of the body (lymphomas) that respond better to treatment with intravenous medication (chemotherapy) and radiation rather than with surgery. At times certain tumors are too large or are located in areas that impinge on blood vessels and nerves, and chemotherapy and radiation help shrink these tumors so that they can be removed surgically later. Expectations after lung surgery: consists of a 5 to 7 day hospital stay, the first 2 to 3 days after surgery in the intensive care unit. These procedures cause a certain amount of discomfort, and most of patients have an epidural catheter (catheter placed by the anesthesiologist, next to one of the outer layers of the spinal cord where the nerves that carry pain sensation are found) to control pain. These epidural catheters are removed after 2 to 3 days and the patients are started on oral pain medication. Patients are highly encouraged and requested to be out of bed in a chair, ambulate (after epidural catheter is removed), deep breath and cough, and expand their lungs with the use of an insentive spirometer. Patients are advised not to drive for the first month, avoid any heavy lifting (no more that 5 lbs) or bending at the waist to pick objects up for 2 months. Patients are advised about the pain of surgery, the expected fatigued state and that both of these things are transient. It is possible to experience discomfort from having the lung surgery through the rib spaces for months, though this is not all the time. Patients that work are allowed to return to work after 2 to 3 months depending on the type of work that they perform. Any patient having been treated for a lung tumor needs careful observation by the physician (s) involved and may require other tests to help with the survey. Always feel comfortable asking questions with respect to findings and options of treatment, as this will help you make better informed decisions.
	DIAGNOSTIC LUNG SURGERY:
	Other diseases affect the lungs such as infections (either bacterial, viral, fungus), collagen vascular diseases (lupus, rheumatoid arthritis, sarcoid), interstital pneumonitis (restriction of lung function that may be caused by exposure to certain particles), and these may be diagnosed by biopsies of the lung that do not entail removal of a lobe or whole lung. Video assisted thoracoscopic surgery (vats) offers a way of draining an infection around the lung, removing a segment of diseased lung or making a diagnosis. Vats provides minimal invasion through the chest wall, with less discomfort and quicker discharge home than with the standard incision through the rib spaces. Also a much smaller incision (s) is/are made to allow the camera to see inside the chest cavity, and the other areas opened to allow instruments to be placed to work on the lung or the surrounding areas. Most patients go home within 1 to 2 days after the surgery, with minimal chest wall discomfort and are able to return faster to work or school. Vats are ideal for those patients who suffer from spontaneous pneumothoracis (congenital thinning of the lung or acquired from smoking or other causes), where the lung air sacs burst and release air into the space between the chest wall and the lung itself, thereby collapsing. This can be a life threatening condition, affecting breathing and return of blood back to the heart. Vats allows these thinned areas to be removed with minimal invasion, and stripping of the chest wall covering (pleurectomy). By removing the chest wall inner tissue, the lung will stick to the chest wall, and future chances of collapse are reduced. other more invasive procedures are avoided if possible to improve patient comfort if at all possible.
	SURGICAL TREATMENT OF LUNG INFECTION:
	Infections affecting the lung tissue may also lead to involvement of the space between the lung and chest wall (pleural space). The organisms that can cause an infection are bacteria, viruses, and fungal elements. with the more aggressive use of antibiotics, lung infections (pneumonias) can usually be treated and not lead to more serious complications, namely, lung abscesses (where the infected lung tissue creates pus and may actually die) or empyemas (when pus and dead lung tissue accumulate at the pleural space or the space between the lung and chest wall). These problems usually require some form of draining. Initially, a tube through the rib space is placed to attempt evacuation of the pus (chest tube), this in most circumstances does not adequately allow removal of all the infected substances. To more completely remove all the pus and debris caused by the infection, one of two things can be done. One, opening the space between the ribs in order to gain access to the lung and the space where the infection is located. This usually requires a larger skin incision than the next procedure. Two, vats (video assisted thoracoscopic surgery) can be used to perform the same function with less of an incision and less postoperative discomfort. With both of the previous procedures (open thoracotomy vs. Vats) chest tubes for drainage are left in place for days to weeks at a time, then slowly removed (approximately 1 inch/week) until the whole tube is removed. Most patients with the type of infections described here will be on intravenous antibiotics for 4 to 6 weeks, and nutritional support is of the upmost importance. The success rate with the above-mentioned steps is reasonable and these are the indicated ways to handle these challenging problems.
	MEDIASTINAL DISEASE:
	Anatomically the mediastinum is that part of the chest that exists between the right and left lungs and their respective pleural spaces. The mediastinum has an anterior, middle and posterior part, and each contains several vital organs (anterior: thymus; middle: heart, aorta, vena cavae, phrenic nerve; posterior: vertebral column, spinal cord, nerve roots, and esophagus). Surgery of the thymus and masses/tumors of the anterior mediastinum is less common, but not unheard of. Enlargement of the thymus gland can occur because of tumor growth (thymoma), increase in the number of cells (hyperplasia), tumors such as lmyphoma can be found here, as well as, the germ cell tumors (tumors that form from primitive cells that have remained in this area since organ formation during the fetal stage). Other organs found in the neck can move into this area of the chest, namely parts of the thyroid gland and parathyroid glands. Diagnosis of the mass is attempted before proceeding surgically, since as discussed earlier, lymphoma can be treated more effectively without surgery in most cases, especially when the disease is diffuse (not localized to one place and spread to different areas). Circumstances of thymic tumors causing myasthenia gravis occur about 15% of the time, and these patients improve their symptoms over the subsequent months after the surgery (myasthenia gravis is a very debilitating disease with progressive loss of muscle function, commonly starting with closing of the eyelid or ptosis. The more muscles involved are used the weaker they become). Surgically, these masses are removed by opening the breast bone or by making incisions in the neck and working down from there. Within the last few years vats has allowed removal of these masses, therefore minimizinge the larger incision.
	THORACIC WALL TUMORS/MASSES:
	These are also not very common, but not to be taken lightly. Tumors of the chest wall can originate in the muscles, ribs, sternum, nerves, and cartilage. Both malignant (more agressive and disorganized tumors) and benign (less agressive, with less likelihood of spreading to other parts of the body) can be found. Any mass, lump or irregularity will require chest x-rays, possible cat scan, bone scan and subsequent biopsy. Total removal of these masses is the primary objective. At times and with certain types of tumors, recurrences are high and therefore need further resections. If a large portion of the chest wall is removed, and a significantly deformed area is left, this is usually reconstructed; depending on it's location. Patients who are successfully treated need close observation by their physician with cat scans, x-rays, bone scans and physical examinations on a routine basis.
	CARDIAC TUMORS:
	Cardiac tumors are rare, nonetheless important, and may be devastating. These tumors can usually be found in the atrial (upper chambers of the heart), ventricles (lower, muscular chambers of the heart), on valves, and involving the nerves conducting the electrical impulses of the heart. atrial myxomas, the most common benign tumors of the heart are one most frequently found. These tumors can reach such large sizes that it is difficult to comprehend how the heart is still able to pump the blood. When malignant tumors affect the heart, survival is much more grim, with many of these patients not surviving one year. This poor survival occurs even when complete removal of the tumor has been done. Other forms of therapy such as chemotherapy and radiation do not affect these heart tumors effectively. Patients with these heart tumors may have no symptoms whatsoever, or have vague symptoms of weight loss, fatigue, possible heart irregularities, and chest pain. some of these masses are friable and pieces of the mass may embolize and cause infarctions (obstruct blood vessels going to brain therefore causing a stroke, or obstruct a blood vessel to the intestine, eye or leg, and leave these areas with no or only slight blood flow). for the above mentioned reasons and concerns, as soon as a diagnosis of a heart tumor is made, it should be surgically removed. For these operations, the patients are under general anesthesia, the standard incision in the breastbone is performed. Other smaller incisions can be performed to alleviate the postoperative recovery. Either approach will require the heart to be stopped and opened to remove the mass. if a wall between chambers has to be removed along with the mass, the defect is reconstructed with either synthetic material or with pericardium (the envelope that covers heart) from the same patient. most of these cases are quicker than other standard heart operations, and tend to be discharged sooner from the hospital. Benign lesions offer an excellent prognosis, but need close surveillance to follow recurrences.

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