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By P. Hengley. Johnson Bible College. 2019.

Before proceeding with surgery it is essential to some series have reported high ureteric injury rates buy generic lasuna 60caps. The surgeon results after uterosacral suspension are similar to those must be convinced that the proposed procedure is achieved with a sacrospinous fixation purchase lasuna 60caps with visa. The 2013 appropriate and must also ensure that the patient Cochrane meta‐analysis of randomized controlled trials knows what can be achieved with surgery and order lasuna 60 caps online, more on apical suspending surgery concluded that the abdom- importantly, what cannot. Surgery for anterior compartment prolapse dominant method of repair; perhaps the addition of api- Anterior vaginal wall defects rarely occur in isolation cal support procedures will lead to improved outcomes. The Surgery for posterior compartment prolapse need to repair other anatomic sites should usually be Posterior repair is associated with much higher rates of decided under anaesthesia when the patient is fully anatomical success, with outcomes as high as 80–95% relaxed and a detailed examination can be carried out. The operation involves a midline plication of the the apical support must be very carefully evaluated as rectovaginal fascia, excision of redundant epithelium it is increasingly believed that anterior compartment and reconstruction of the epithelium. This is borne out by has never been shown to have advantages over native tis- significantly better surgical outcomes when an anterior sue repair. Improvement in bowel symptoms has been repair is performed concurrently with an apical support demonstrated in the majority of women after posterior repair [41]. Traditionally, the anterior repair involves the midline Patients who present with significant prolapse of the plication of the vaginal fascia followed by excision of the anterior and posterior walls often have concomitant loss redundant vaginal wall epithelium and then suture of the of apical support. Repair of the anterior wall may also involve is poorly supported, there is a lower chance of support- correction of lateral wall defects. Obliterative surgical procedures Anterior wall surgery has success rates in the range of Obliterative procedures are reserved for women who 40–60% [42]. Because of these poor results, surgeons have failed conservative therapy but who have significant have started to use artificial grafts to try to improve out- comorbidities and are therefore not candidates for exten- comes. In a study of 2756 women it was shown that sive surgery and who do not plan for future vaginal inter- the addition of an apical supporting procedure to an course. Uterovaginal Prolapse 763 the procedure involves removal of strips of vagina Summary box 55. Restorative the main purpose of the side strips is to allow for vaginal Vaginal or uterine secretions to be discharged. Synthetic materials are further defined according to the type of polymer (absorbable or Abdominal non‐absorbable, monofilament or multifilament), pore ● Sacrocolpopexy (open/laparoscopic/robotic). These features will determine how the ● Sacrohysteropexy (open/laparoscopic/robotic). Microporous and multifilamentous grafts cause an over‐exuberant inflammatory reaction with subse- the future quent tissue damage [47]. Early data suggested that traditional repair was associ- With an ageing population with an increasingly sedentary ated with more postoperative prolapse as seen on exami- lifestyle and endemic levels of obesity, the number of nation and also as reported by patients [44]. These were better delineate the problems and hopefully develop more marketed very aggressively and with little regard to effective solutions. This appeared with mesh complications, including extrusion, will involve the monitoring of operative morbidity as well infection, shrinkage and fibrosis. Improved outcome Multiple law suites materialized all over the world, data will allow us to understand the natural history of the which led many manufacturers to withdraw their prod- condition, which in turn will help us counsel our patients ucts from the market. Hopefully support the safety and effectiveness of the synthetic there will be newer and better graft materials to help mesh [48]. These may or may not include a surgery has dropped from a high of 27% of surgeries in contribution from stem cell technology. Lifetime risk of stress urinary incontinence or hysterectomy surveillance in the United States, 2000– pelvic organ prolapse surgery. Prevalence of genital prolapse risk of undergoing surgery for pelvic organ prolapse. Int Urogynecol J Textbook of Female Urology and Urogynaecology, 3rd 2013;24:1783–1790. Control Clin Trials a woman’s first delivery and the implications for pelvic 2003;24:629–642. Nonobstetric risk factors for colposuspension versus endopelvic fascia plication for symptomatic pelvic organ prolapse. Obstet Gynecol potential stress incontinence prophylaxis in women 2009;113:1089–1097. Int Urogynecol J Pelvic Incidence of pelvic floor repair after hysterectomy: a Floor Dysfunct 2009;20:1157–1161. Am J Obstet Gynecol 33 Heit M, Rosenquist C, Culligan P, Graham C, Murphy 2007;197:664. Predicting treatment choice for patients Uterovaginal Prolapse 765 with pelvic organ prolapse. Obstet Gynecol total vaginal mesh for vaginal vault prolapse: a 2003;101:1279–1284. Obstet Gynecol Anterior colporrhaphy: a randomized trial of three 2000;95:931–935. Outcomes of pessary fitting trial in women with pelvic organ vaginal prolapse surgery among female Medicare prolapse. J Clin Endocrinol colpocleisis on bowel symptoms among women with Metab 2014;99:3728–3736. Hospital level under‐utilization of surgical mesh for transvaginal pelvic organ prolapse minimally invasive surgery in the United States: repair. Other of life of women and urgency incontinence has been gynaecological symptoms such as prolapse or menstrual found to be associated with increased mortality [1]. A fibroid uterus may com­ Through ignorance, embarrassment and a belief that loss press the bladder and can cause urinary frequency and of bladder control is a ‘normal’ result of childbirth and urgency. There is an increased incidence of stress incon­ ageing, many women suffer for years before seeking tinence amongst women who have had large babies, par­ help [2]. An accurate diagnosis can be made and many ticularly following instrumental vaginal delivery, so an women can be cured or improved by the use of various obstetric history may be helpful. Both continence and micturition depend on a tion of a neurological problem (such as multiple sclerosis) structurally and functionally normal lower urinary tract. There are a number of responsible for symptoms of lower urinary tract dys­ additional causes of urinary incontinence in elderly function and should therefore be recorded. In older people they may cause urinary incontinence where only urgency existed previously. Other drugs that affect detrusor func­ Clinical presentation of urinary tion include tricyclic antidepressants, major tranquillizers incontinence and α‐adrenergic blockers. Unfortunately, clinical examination is usually unhelp­ Symptoms of lower urinary tract dysfunction fall into ful in cases of female urinary incontinence.

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Yamamoto M buy discount lasuna 60caps online, Sobue G cheap lasuna 60caps amex, Mukoyama M purchase lasuna 60 caps with mastercard, et al: Demonstration of slow acetylator genotype of N-acetyltransferase in isoniazid neuropathy using an archival hematoxylin and eosin section of a sural nerve biopsy specimen. Blumberg H, Burman W, Chaisson R, et al: American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Tostmann A, Boeree M, Aarnoutse R, et al: Antituberculosis drug- induced hepatotoxicity: concise up-to-date review. O’Brien R, Long M, Cross F, et al: Hepatotoxicity from isoniazid and rifampin among children treated for tuberculosis. Timbrell J, Mitchell J, Snodgrass W, et al: Isoniazid hepatotoxicity: the relationship between covalent binding and metabolism in vivo. Chin L, Sievers M, Herrier R, et al: Convulsions as the etiology of lactic acidosis in acute isoniazid toxicity in dogs. Chin L, Sievers M, Herrier R, et al: Potentiation of pyridoxine by depressants and anticonvulsants in the treatment of acute isoniazid intoxication in dogs. Chin L, Sievers M, Laird H, et al: Evaluation of diazepam and pyridoxine as antidotes to isoniazid intoxication in rats and dogs. Skinner K, Saiao A, Mostafa A, et al: Isoniazid poisoning: pharmacokinetics and effect of hemodialysis in a massive ingestion. In the 1940s, lithium chloride was briefly marketed as a salt substitute, but was withdrawn after several cases of serious intoxication and death resulted from its use. In 1949, its antimanic properties were reported, and lithium has found increasingly wide psychiatric use since its approval by the U. Lithium treatment in psychiatric diseases has been modified over five decades, but it remains a cornerstone “mood stabilizer” that is used worldwide [2]. Many studies have shown the benefits of lithium as a treatment for bipolar disorder, acute mania, and bipolar depression; however, recommendations concerning its clinical use vary among international guidelines. Lithium is recommended as monotherapy, as first-line treatment, or in combination with other antidepressive or antipsychotic agents based on different clinical scenarios and various guidelines [3]. Lithium has not been widely used in patients with thrombocytopenia despite evidence of megakaryocytopoiesis and thrombopoiesis demonstrated in a few studies [4,5]. It is important to note that although lithium carbonate and lithium citrate are the commonly prescribed forms, other lithium salts (lithium acetate, lithium gluconate, lithium orotate, and lithium sulphate) are also available in some countries [6]. It inhibits glycogen synthase kinase-3, a component of diverse signaling pathways responsible for energy metabolism, neuroprotection, and neuroplasticity. Lithium decreases the release of norepinephrine and dopamine from terminal nerve endings and may temporarily increase the release of serotonin. Lithium affects ion transport and cell membrane potential by competing with sodium and potassium and possibly other cations. However, unlike sodium and potassium, lithium does not produce a large distribution gradient and, therefore, cannot maintain a significant membrane potential [6,7]. The bioavailability of conventional tablets and capsules and the liquid solution is 95% to 100%; bioavailability is not affected by food. Modified-release preparations are less predictably absorbed (60% to 90%), and peak levels may be lower than with the conventional form and may be delayed by more than 4 to 12 hours [6–8]. Overdose has resulted in delayed peak levels or secondary peak levels as long as 148 hours following ingestion [8]. After a single dose, the equilibrium (postdistributional) serum lithium concentration can be expected to increase by 1. Tissue distribution is uneven; whereas the cerebrospinal fluid lithium concentration is only 50% to 80% that of plasma, the bile concentration may be two times greater than that of plasma. One animal study demonstrated that brain lithium accumulation is prominent in acute-on-chronically poisoned rats compared with acutely poisoned rats. Moreover, brain lithium distribution is increased in chronically poisoned rats compared with acute-on-chronically poisoned rats [9]. More than 95% of absorbed lithium is excreted by the kidneys, with 4% to 5% eliminated in sweat and 1% in the feces. Eighty percent of renally filtered lithium is reabsorbed in the proximal tubule (60%) and the thick ascending limb of the loop of Henle and collecting duct (20%) against a concentration gradient that does not distinguish lithium from sodium. The usual renal clearance is 15 to 30 mL per minute, but it may be 10 to 15 mL per minute or less in the elderly and in patients with renal dysfunction or dehydration [6]. One study demonstrated increased fractional excretion of lithium in patients with prerenal failure, but decreased fractional excretion in acute tubular necrosis renal failure [10]. The elimination half-life averages 16 to 30 hours; in patients with chronic intoxication, it may be as long as 58 hours [7,11]. Therapeutic levels are achieved by administration of 600 to 1,200 mg (16 to 32 mmol) of lithium carbonate per day in adults. Drug levels should be drawn at least 12 hours after the last dose to allow for complete tissue distribution. Onset of therapeutic effects usually requires 5 to 21 days after initiation of daily drug administration. Careful monitoring of lithium levels is essential because of its low toxic-to-therapeutic ratio or so-called narrow therapeutic index [2,3,12]. Lithium intoxication may follow an acute overdose, an increase in the daily therapeutic dose, or a decrease in lithium elimination by the kidneys. Most serious toxicity occurs in patients with chronic intoxication, especially in older patients and patients with renal insufficiency [11]. Acute ingestion of at least 40 mg per kg (1 mmol per kg) of lithium carbonate in a lithium-naive person would be required to produce a potentially toxic serum lithium level. The acute toxic dose in a patient already taking lithium (“acute-on-chronic” overdose) depends on the existing serum lithium level (“tissue soaking”). The dose required to produce chronic intoxication depends on the individual’s rate of renal lithium elimination. Classification for severity of lithium intoxication may be based on serum lithium concentration: mild (1. However, there does not appear to be a clear-cut relationship between serum concentrations and severity of toxicity, and decisions for treatment should be based on clinical parameters [13]. Symptoms and signs of mild lithium intoxication include nausea, vomiting, lethargy, fatigue, memory impairment, and fine tremor. Moderate signs and symptoms of toxicity include confusion, agitation, delirium, coarse tremor, hyperreflexia, hypertension, tachycardia, dysarthria, nystagmus, ataxia, muscle fasciculations, extrapyramidal syndromes, and choreoathetoid movements. Patients with severe toxicity may also exhibit bradycardia, complete heart block, coma, seizures, nonconvulsive status epilepticus (which may clinically resemble a nonictal encephalopathy), hyperthermia, neuroleptic malignant syndrome, serotonin syndrome, and hypotension [14].

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In England discount lasuna 60 caps otc, about one-third of primiparous women resumed intercourse by 6 weeks effective lasuna 60caps, and nearly everyone by 3 months generic lasuna 60 caps online. In this study, 9% of exclusively breast- feeding women had resumption of menses by the end of 3 months and 19% by the end of 6 months. This increased suppression of fertility undoubt- edly refected the intensity of the breastfeeding program and the motivation of the participants. When these two conditions are fulflled, breastfeeding provides more than 98% protection from pregnancy in the frst 6 months. The Postpartum Period, Breastfeeding, and Contraception Full breastfeeding means that the infant’s total suckling stimulus is directed to the mother. The Bellagio degree of protection in the frst 6 months of full or nearly full breastfeeding has been confrmed in clinical studies. The duration of postpartum lochia is variable and can make it difcult to detect the onset of menstrual bleeding. Only amenorrheic women who exclusively breastfeed at regular inter- vals, including nighttime, during the frst 6 months have the contraceptive protection equivalent to that provided by oral contraception; with men- struation or afer 6 months, the risk of ovulation increases. It is rooted in old texts and teachings from a time when infection was prevalent and before modern methods of contraception were available. The 6-week visit and pelvic exami- nation were based on the understanding that a 6-week period of time would result in sufcient involution of the changes of pregnancy to allow an efec- tive examination that would establish the return of normal pelvic anatomy. Many women resume sexual activity before the sixth postpartum week, and because ovulation frequently returns before 6 weeks, the obstetrical tradition of scheduling the postpartum visit at 6 weeks should be changed. A 3-week visit would be more efective in avoiding postpartum surprises, preventing postpartum conception by earlier initiation of efec- tive contraception. Tere is no reason why a complete physical examination cannot be deferred in an asymptomatic woman until the 3-month follow-up visit that is part of good contraceptive care. Tat is not to say that full breastfeeding should not be encouraged and that the protection obtained in the frst 6 months of breastfeeding should not be emphasized. Half of women studied who are not fully breastfeeding ovulate before the sixth week, the time of the traditional postpartum visit; a visit during the third postpartum week is strongly recommended for con- traceptive counseling. Afer the spontaneous or elective termination of a pregnancy of less than 12 weeks, steroid contraception can be started immediately. Afer a preg- nancy of 12 or more weeks, the third postpartum week rule should be fol- lowed if the pregnancy is term or near term to avoid the postpartum risk of venous thromboembolism (discussed later). Traditionally, the frst medical visit afer delivery has been scheduled at 6 weeks, a time when good involution of the uterus and healing have occurred. We urge clinicians and patients to start a new tradition: schedule the frst postpartum visit during the third week afer delivery. Even breastfeeding women should be evaluated at this time, to consider whether breastfeeding is full and exclu- sive, or whether an additional contraceptive method is necessary. Steroid Contraception Oral contraception even in low-dose formulations has been demonstrated to diminish the quantity and quality of lactation in postpartum women. Although there has been concern regarding the potential hazard of transfer of contraceptive steroids to the infant (a signifcant amount of the proges- tational component is secreted into breast milk),94,95 no adverse efects have thus far been identifed. Because iron is an important factor in the bacterio- static activity of breast milk, it is good to know that iron and copper concen- trations in breast milk are not afected by the use of oral contraceptives. Because of the concern regarding the impact of oral contraceptives on breastfeeding, a useful alternative is to combine the contraceptive efect the Postpartum Period, Breastfeeding, and Contraception of lactation with the progestin-only minipill (see Chapter 3); there is no evidence for any adverse efect on breastfeeding as measured by milk vol- ume and infant growth and development. In contrast to the combined oral contraceptive, the progestin-only minipill even provides a modest boost to milk production, and women using the minipill breastfeed longer and add supplementary feeding at a later time. In addition, the minipill can protect against the bone loss associated with lactation, a poten- tial advantage in undernourished women. Because of the slight posi- tive impact on lactation, the minipill can be started immediately afer deliv- ery. In the past, the risk of venous thromboembolism was believed to be concentrated in the postpartum period. It is now apparent that the postpartum incidence of this problem has decreased, and antepartum diagnosis is now more common. Undoubtedly a contributing factor to this change is the now common prac- tice of early ambulation afer delivery. Over a 30-year period in Minnesota, the incidence of antepartum venous thromboembolism remained constant, but postpartum cases decreased more than 2-fold; nevertheless the num- ber of cases was still fve times higher among postpartum women compared with pregnant women. The increase of venous thromboembolism begins shortly afer concep- tion, is maintained throughout pregnancy and the frst week postpartum, and then gradually declines, reaching baseline levels about 4 to 6 weeks A Clinical Guide for Contraception postpartum. To minimize the risk of postpartum venous throm- boembolism, good contraceptive practice has for decades emphasized the avoidance of exposure to pharmacologic levels of estrogen immediately afer delivery. Terefore, we recommend that nonbreastfeeding mothers use a progestin-only contraceptive method beginning in the third postpar- tum week; a change to a combination estrogen-progestin method can be initiated in the seventh postpartum week. This recommendation also applies to the vaginal and transdermal methods of estrogen-progestin contraception. Depot-Medroxyprogesterone Acetate Depot-medroxyprogesterone acetate does not afect breastfeeding or infant growth. Although studies have not been reported with use within 30 days afer delivery, there are no efects associated with this method that require cau- tion. Depot-medroxyprogesterone acetate can be administered immediately postpartum, and certainly should be utilized no later than the third post- partum week. Because the oral progestin-only minipill increased the risk of diabetes mellitus in breastfeeding, overweight Latino women with prior gestational diabetes,107 depot-medroxyprogesterone acetate should be used with caution in all women with previous gestational diabetes. Contraceptive Implants Studies in Egypt indicated that when Norplant was inserted at least 30 to 42 days postpartum, the only diference in lactation or infant growth and development comparing Norplant users and controls was that infant weight gain in the frst few months with exclusively breastfeeding Norplant users was slightly less. The implant was placed at 6 weeks postpartum; no efect was observed on breast milk quantity and quality, infant growth, or duration of breastfeeding. As noted above, women using levonorgestrel-only minipills have a better breastfeeding experience, beginning supplementary feeding about 1 month later and one-third are likely to discontinue breastfeeding compared with women using nonhormonal contraceptives. The transfer of progestin from the mother’s circulation to her milk and thence to the infant’s blood has been studied with three delivery systems for levonorgestrel (minipill, implant, and intrauterine contraception). As noted above, the oral progestin-only minipill increased the risk of non–insulin-dependent diabetes mellitus in breastfeeding, overweight Latino women with prior gestational diabetes. No studies have been reported examining the efects of implant admin- istered prior to 30 days afer delivery, and, therefore, the package advisory insert cautions against immediate postpartum use. In some situations, how- ever, the delivery may provide the only opportunity to receive implant con- traception.

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The residual Gore-Tex material should then be removed from the right pulmonary artery and this area is enlarged with an oval-shaped patch of autologous pericardium or pulmonary homograft discount lasuna 60 caps overnight delivery. Division of the Gore-Tex Shunt Theoretically lasuna 60caps line, as a child grows purchase lasuna 60 caps without prescription, an intact Gore-Tex tube graft may cause upward traction on the right pulmonary artery, which may lead to distortion and possible late development of pulmonary artery stenosis. If an adequate length of Gore-Tex tube graft can be dissected free without incurring excessive bleeding, the tube may be secured with two metal clips on each side and divided to prevent this potential late complication. Left-Sided Modified Blalock-Taussig Shunts Isolation of the left-sided shunt is somewhat more cumbersome and can be accomplished in many ways. Alternatively, the left pulmonary artery is dissected free from within the pericardium, and the Gore-Tex tube graft is clipped just above its junction with the pulmonary artery. Central Shunt With the initiation of cardiopulmonary bypass, the Gore-Tex tube graft is occluded with a metal clip. Prosthetic Ascending Aorta-Right Pulmonary Artery Shunt the tube graft is carefully dissected free from the lateral aspect of the ascending aorta and occluded with a metal clip as cardiopulmonary bypass is commenced. Usually, the shunt tubing is divided while on bypass and the aortic and pulmonary ends are oversewn with a running 6-0 or 5-0 Prolene suture. The correct plane for dissection must be identified, staying right on the Gore-Tex graft itself to avoid entry into the aorta. If the shunt cannot be safely dissected from the aorta, it should be occluded as much as possible with a vascular clamp or forceps when cardiopulmonary bypass is commenced and the dissection completed with the patient on bypass. Waterston and Potts Shunts Waterston and Potts shunts are no longer performed, but familiarity with the techniques of their closure is essential for the surgeon who operates on patients who have undergone these shunting procedures in the past. Technique: Waterston Shunt the easiest way to close a Waterston shunt is on cardiopulmonary bypass with the aorta cross-clamped. After administering cardioplegic solution, a small transverse aortotomy is made, and the shunt may be closed from within the aorta with a few interrupted sutures. The preferred method is to detach the right pulmonary artery from the aorta and oversew the defect in the ascending aorta with a running 5-0 Prolene suture. The defect in the pulmonary artery can be closed transversely by direct suture or preferably patched with a piece of autologous pericardium or pulmonary homograft. Pulmonary Artery Distortion If the shunt has created some stenosis or kinking of the right pulmonary artery, this should be reconstructed with an appropriate pericardial or homograft patch. Flooding of the Pulmonary Circulation the site of the shunt must be occluded with the initiation of cardiopulmonary bypass, or flooding of the lungs will occur. If this cannot be achieved with a vascular forceps or clamp, the right and left pulmonary arteries should be encircled before beginning cardiopulmonary bypass, and snared or clamped. Technique: Potts Shunt Closure of Potts shunt is performed on cardiopulmonary bypass with moderate hypothermia. The patient is placed in the Trendelenburg position, and with the heart decompressed, the perfusion pressure is temporarily reduced. The site of a shunt orifice in the left pulmonary artery is identified and closed with a purse-string suture or patch. Flooding of the Pulmonary Circulation Before instituting cardiopulmonary bypass, the site should be identified by palpating for a thrill along the left pulmonary artery. Air Embolism through Aortic Opening When the left pulmonary artery is opened, some flow must be maintained through the aortic cannula to prevent air embolism. In addition, there is a real or potential slit-like opening, the foramen ovale, where the fossa ovalis flap disappears behind the superior septal limbus. Generally, the higher pressure in the left atrium keeps the fossa ovalis flap in apposition to the superior septal limbus, and therefore the opening remains closed. In 20% of the population, however, the foramen ovale is patent and has the potential to allow shunting under certain circumstances. When pressure in the right atrium increases, as in right- sided heart failure, the septum becomes stretched and allows the foramen ovale to enlarge with significant shunting at the atrial level. The sinus venosus atrial septal defect occurs high in the atrial septum and extends into the orifice of the superior vena cava, which becomes malpositioned slightly toward the left. There is usually anomalous drainage from the right superior pulmonary vein associated with these defects. This defect occurs in the midseptum in the vicinity of the fossa ovalis and may be small or very large. Infrequently, the defect may occur low in the septum and extend into the orifice of the inferior vena cava, which also becomes malpositioned toward the left. This type of defect is sometimes referred to as a sinus venosus defect of the inferior vena caval type and may be associated with anomalous pulmonary venous drainage. A defect low in the interatrial septum that extends down to the level of the atrioventricular valve orifices is part of the atrioventricular septal defect complex (see Chapter 22). Systemic venous return flows in from opposing directions through the superior and inferior venae cavae into the sinus venarum. This smooth-walled area is the most posterior portion of the right atrium and stretches between the orifices of the caval veins. From the viewpoint of the surgeon looking down into the right atrium, the sinus venarum is more or less horizontal with the superior vena cava entering from the left and the inferior vena cava (bounded by the eustachian valve) entering from the right. Just below and medial to the orifice of the superior vena cava arises a muscle bundle, the crista terminalis, which springs into prominence as it circles the orifice of the superior vena cava to the right lateral wall of the atrium and continues inferiorly toward the inferior vena cava, thereby forming the boundary between the sinus venarum and the atrial appendage. Lying subepicardially in the sulcus terminalis, just below the entrance of the superior vena cava, is the sinoatrial node, which may be vulnerable to injury from the various surgical incisions and cannulations commonly performed on the right atrium. In contrast with the smooth-walled sinus venarum, the lateral wall of the atrial appendage is ridged with multiple narrow bands of muscle, the musculi pectinati. Functionally, they supply the right atrium with enough pumping capacity to propel the venous inflow through the tricuspid valve into the right ventricle. Just above the sinus venarum in the center of the medial wall is the fossa ovalis, a horseshoe- or elliptically shaped depression. The true interatrial septum consists of the fossa ovalis with variable contributions from the superior, anterior, and inferior limbic muscle bundles that surround it. The aortic root is hidden behind the anteromedial atrial wall between the fossa ovalis and the termination of the heavily trabeculated right atrial appendage.

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