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Cardiopulmonary
Transplantation and
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Support
ii

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Cardiopulmonary
Transplantation
and Mechanical
Circulatory
Support
edited by
Maziar Khorsandi, Steven Tsui,
John Dark, Alan J. Kirk,
Matthew Hartwig,
Mani A. Daneshmand, and
Carmelo Milano
illustrated by
Jay LeVasseur
iv

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To my parents Shahin and Ali Khorsandi, MD and to the memory
of Edward “Ted” Brackenbury, FRCS
vi
 vii

Foreword
When people speak of vitality, it is often with reference to cardiorespira-
tory function. Indeed, throughout human history people have intuitively
associated heart and lung function with one’s life, virtue, and soul. Thus,
when heart and lung transplantation emerged in the 1960s, it captured the
world’s attention far more than kidney or liver transplantation. After all, we
associate ourselves with every heartbeat, every breath; not so much with
urine and bile. It was as though successful replacement of the heart and
lungs forced us to consider our humanity, and thus seemed more miracu-
lous than technical.
The past 60 years have led the elements of pulse and breath to be char-
acterized so well that they are now regularly exchangeable. The world is
approaching its 100,000th cardiopulmonary transplantation, and mechan-
ical support devices are rapidly becoming commonplace. With such preva-
lence, one would think that cardiopulmonary replacement might have lost
its lustre. Yet every time I think about a heart or lung transplant, or a left
ventricular assist device deployment, it still seems like a miracle to me—​not
because the mechanics and biology are mysterious, but rather because they
are now so well defined. To be sure, it is immensely technical, and it is the
enormity of what we now know about this practice that makes it so im-
pressive. Assembling that knowledge into a usable format is increasingly
important and challenging.
In saying that transplantation is technical, it is not to imply that it is amen-
able to rote education. There is really no transplant procedure that is
exactly like another. Each case has its unique physiology, immunology, and
histocompatibility, the latter of which literally defines individuality. There
are so many reasons that this should not work, yet it does, almost routinely.
I believe this is a tribute to the dedicated people who try to make sense
of each case and derive and curate generalizable insights. Cardiopulmonary
Transplantation and Mechanical Circulatory Support is a collection of those
insights, to be used in the adept navigation of each improbable success.
This is a concise resource to help practitioners quickly refresh the relevant
information needed to recognize problems and deal with them. This is not
a comprehensive treatise, as each chapter could warrant a book in and unto
itself. Rather, this is a means of practical guidance, placing clinical challenges
into the broad contexts of cardiopulmonary physiology and transplant im-
munology. It will be particularly useful to trainees, and to nurses, advanced
practice providers, intensivists, and hospitalists caring for transplant patients
and needing quick reference. This is a resource to provide order to the rap-
idly accumulating practical information needed to routinely transform lives,
one miracle at a time.
Allan D. Kirk, MD, PhD, FACS
David C. Sabiston, Jr. Distinguished Professor of Surgery,
Immunology and Pediatrics
Chairman of the Department of Surgery
Duke University Medical Center
Durham, NC, USA
vii
 ix

Foreword
Cardiopulmonary Transplantation and Mechanical Circulatory Support
will serve as a valuable resource for residents, fellows, and advanced care
practitioners. Thirty-​eight chapters cover a variety of important topics, rep-
resenting several years of effort by an international slate of authors and
editors. While much of what we do in surgery for advanced heart and lung
failure is evidence based, a substantial amount of it is also based on per-
sonal opinion, consensus, and institutional preference. What is presented
here falls into the latter category. However, trainees require a foundational
understanding of key concepts and techniques to begin their education in
the field. This handbook is a practical guide and an excellent starting point
for individuals learning to practice in this field. By no means is this intended
as a definitive treatment on this topic but rather to lay the ground work for
lifelong learning. Managing Editor Maz Khorsandi will be updating this hand-
book to ensure content remains current.
Those who possess a highly-​developed awareness of this field and know-
ledge of related literature may take issue with some of the points made
in the text. However, authors have attempted to simplify the concepts in
order to make them more approachable to the reader. The best use of
this handbook would be for study preparation by trainees with directed
follow-​up discussion with their attending providers, as well as focused lit-
erature searches to enhance and refine their depth of understanding. As
these fields continue in their inevitable evolution, the stewardship of con-
tinued learning will require humility and receptiveness to new concepts and
ideas that challenge existing notions, concepts, or dogma. This handbook is
a starting point that is very readable, approachable, and useful. As such, it
should inspire readers to engage in this complex and rapidly-​evolving field
and serve as a catalyst for advanced learning.
Michael S. Mulligan, MD
Professor and Chief, Division of Cardiothoracic Surgery
Endowed Professor in Lung Transplant Research
Director, Lung Transplant Program
University of Washington
x
 xi

Preface
As I approached the final stretch of my specialty training in cardiothoracic
surgery, I felt that there was a paucity of a quick reference manual for my
subspecialty field of interest, cardiopulmonary transplantation and mech-
anical circulatory support. Most reference guides were large, cumbersome,
and already outdated by the time they were published. Henceforth, I felt
the need to embark on this handbook project. I was further encouraged
and supported by my mentors Dr Carmelo Milano, MD, Duke University
Medical Center, USA, and Mr Edward ‘Ted’ Brackenbury, FRCS C/​Th,
Royal Infirmary of Edinburgh, UK. Furthermore, Duke University Heart
Center generously supported the project financially.
Cardiopulmonary Transplantation and Mechanical Circulatory Support is a
comprehensive yet succinct and readily available pocket guide of the most
up-​to-​date developments in the field of heart and lung transplantation and
mechanical circulatory support. The most prominent and globally respected
experts in Europe and North America were selected as editors and authors
for this handbook and the content, for the most part, reflects their personal
experience, hints, and tips for practitioners on the front line. The handbook
is accompanied by informative text and high-​resolution practical illustrations
making it relevant to all tiers of healthcare professionals such as nurses,
advanced care practitioners, surgical, medical, and critical care residents
and fellows, as well as junior attending/​consultant physicians and surgeons
looking after such critically ill patients. This handbook will be readily avail-
able both as a hard copy and online. I strive to continuously update it with
the most recent evidence-​based practice.
Maziar Khorsandi, FRCS C/​Th
Assistant Professor of Surgery
Attending Cardiothoracic Surgeon
Division of Cardiothoracic Surgery
University of Washington Medical Center
Seattle, WA, USA
xii
 xiii

Acknowledgements
We would like to gratefully acknowledge the generous donation by Duke
University Heart Center in funding the illustrations for this handbook.
xvi
 xv

Contents
Contributors xix
Abbreviations xxvii

Section 1 Heart failure

1 Medical and minimally invasive aspects of heart
failure management 3
Marc D. Samsky and Joseph G. Rogers

2 Myocarditis: diagnosis and treatment 15

Stuart D. Russell

3 Cardiac amyloidosis and other restrictive

myopathies: diagnosis and treatment 27
Rahul Loungani and Chetan Patel

Section 2 Mechanical circulatory support

4 Indications for ventricular assist devices 41
Antonios Kourliouros

5 Surgical techniques for left ventricular assist device

implantation and associated procedures 49
Igor Gosev and Scott Silvestry

6 Clinical trials with durable left ventricular

assist devices 61
Yuting P. Chiang and Mani A. Daneshmand

7 Diagnosis and management of ventricular assist

device complications 69
Maziar Khorsandi, Philip Curry, Sukumaran Nair, and
Nawwar Al-​Attar

8 Extracorporeal membrane oxygenation 79

Jeffrey Javidfar, Maziar Khorsandi, and Mani A. Daneshmand

9 Percutaneous mechanical circulatory support 97

Dominick Megna Jr, Maziar Khorsandi, and Danny Ramzy
 xvi Contents

109 10 The total artificial heart

Dominick Megna Jr and Francisco Arabia

117 11 Post-​cardiac surgery cardiogenic shock

Maziar Khorsandi, Philip Curry, Nawwar Al-​Attar, and
Sukumaran Nair

Section 3 Heart transplantation

12 Patient selection criteria and bridging
131 support for cardiac transplantation
Julie Doberne, Benjamin Bryner, and Chetan Patel

139 13 Cardiac donor selection and management

Ahmed S. Al-​Adhami, Hari Doshi, Nawwar Al-​Attar, and Philip Curry

14 Extended criteria heart donors and

157 perfusion storage
Yaron Barac, Anthony Castleberry, Jacob Schroder, and
Sebastian V. Rojas

15 Donor heart procurement: donation after

brain death and donation after circulatory
171 determined death
Simon Messer, Stephen Large, Marius Berman, and Steven Tsui

185 16 Technical aspects of heart transplantation

Yaron Barac, Christopher White, and Jacob Schroder

17 Critical care management and primary

195 graft dysfunction following cardiac transplantation
Sanjeet A. Singh, Jonathan R. Dalzell, Sukumaran Nair, and
Andrew Sinclair

18 Assessment and management of chronic

209 complications following heart transplantation
Anna K. Barton, Alison I. Smyth, Alan J. Kirk, and Jonathan R. Dalzell

19 Bedside care and rehabilitation with

mechanical circulatory support and
225 thoracic transplantation
Desiree Bonadonna, Lynn McGugan, and Evelyn Watson
 Contents xvii

20 Management of rejection following cardiac

transplantation 233
Sounok Sen and Adam D. DeVore

21 Antimicrobial prophylaxis and treatment of

infection after cardiac transplantation 247
Sana Arif, Sylvia Costa, and Barbara D. Alexander

Section 4 Heart failure in paediatric patients

22.1 Heart transplant for paediatric patients 267
Mohamed Nassar and Asif Hasan

22.2 Paediatric extracorporeal membrane oxygenation 275

Louise Kenny, Ed Peng, and Asif Hasan

22.3 Paediatric heart transplant: specific considerations 287

Ed Peng and Asif Hasan

Section 5 Special considerations in heart

transplantation
23 Adult patients with congenital heart disease 303
Louise Kenny and Asif Hasan

Section 6 Lung transplantation

24 Patient selection criteria and bridging support for
lung transplantation 319
Basil Nasir and John M. Reynolds

25 Lung donor selection and management 337

Stephen C. Clark

26 Lung procurement following donation after brain

death and donation after circulatory death 347
Julie Doberne, Jacob Klapper, and Matthew Hartwig

27 Ex vivo lung perfusion 355

Anders Andreasson, Karen Booth, John Dark, and Abbas Ardehali
xviii Contents

371 28 Technical aspects of lung transplantation

Basil Nasir, Pedro Catarino, and John Haney

29 Critical care management and primary

383 graft dysfunction following lung transplantation
Michael Mulvihill, Nathan Waldron, and Matthew Hartwig

30 Management of rejection following lung

389 transplantation
Lorenzo Zaffiri and Arun Nair

399 31 Late complications following lung transplantation

Yejide Odedina, Jagan Murugachandran, and Jasvir Parmar

32 Antimicrobial prophylaxis and treatment

411 after lung transplantation
Karen Booth and Julie R. Samuel

Section 7 Combined transplantation

423 33 Combined heart–​lung transplantation
Jason Ali, Jasvir Parmar, and Steven Tsui

439 34 Combined thoracoabdominal organ transplantation

Yaron Barac, Jigesh A. Shah, Jacob Schroder, and Andrew S. Barbas

Section 8 Anaesthetic considerations

35 Anaesthetic issues related to
extracorporeal membrane oxygenation
449 and ventricular assist device procedures
Michael W. Manning and Kamrouz Ghadimi

459 36 Anaesthetic issues related to heart transplantation

Philip McCall, Alina Nicoara, and Andrew Sinclair

469 37 Anaesthetic issues related to lung transplantation

Brandi Bottiger, Nazish Hashmi, and Mihai Podgoreanu

Index 481

Contributors
Ahmed S. Al-​Adhami,
FRCS C/​Th
Specialty Registrar
Department of Cardiothoracic
Surgery
Golden Jubilee National Hospital
Glasgow, UK
Chapter 13
Nawwar Al-​Attar, FRCS
C/​Th, PhD
Director of Heart Transplantation
and Consultant Cardiac and
Transplant Surgeon Department of
Cardiothoracic Surgery
Golden Jubilee National Hospital
Glasgow, UK
Chapters 7,11,13
Barbara D. Alexander, MD
Professor of Medicine and
Pathology
Division of Infectious Diseases
Duke University Medical Center
NC, USA
Chapter 21
Jason Ali, MRCS, PhD
Speciality Registrar in
Cardiothoracic Surgery
Department of Cardiothoracic
Surgery
Royal Papworth Hospital
Cambridge, UK
Chapter 33
Anders Andreasson, FRCS
C/Th, PhD
Speciality Registrar in
Cardiothoracic Surgery
Department of Cardiothoracic
Surgery
Freeman Hospital
Newcastle, UK
Chapter 27
xix
Francisco Arabia, MD
Professor of Surgery
Division Chief of Cardiothoracic
Surgery
University of Arizona College of
Medicine
AZ, USA
Chapter 10
Abbas Ardehali, MD
Director of UCLA Heart and Lung
Transplantation Program
Professor of Surgery and William E
Conner Chair of Cardiopulmonary
Transplantation Division of
Cardiothoracic Surgery
Ronald Reagan UCLA Medical Center
CA, USA
Chapter 27
Sana Arif, MBBS
Assistant Professor of Medicine
Division of Infectious Diseases
Duke University Medical Center
NC, USA
Chapter 21
Yaron Barac, MD, PhD
Associate Professor of Surgery and
Cardiovascular Physiology
Director
Heart and Lung Transplant and
Mechanical Circulatory Support
Program
Rabin Medical Center
Sackler Faculty of Medicine
Tel Aviv, Israel
Chapters 14,16,34
Andrew S. Barbas, MD
Assistant Professor of Surgery
Division of Abdominal Transplant
Surgery
Duke University Medical Center
NC, USA
Chapter 34
xx Contributors
Anna K. Barton, MSc, MRCP
Clinical Research Fellow and
Honorary Cardiology Registrar
Centre for Cardiovascular Science
The University of Edinburgh
Edinburgh, UK
Chapter 18
Marius Berman, FRCS C/​Th
Consultant Cardiac and Transplant
Surgeon
Department of Cardiothoracic
Surgery
Royal Papworth Hospital
Cambridge, UK
Chapter 15
Desiree Bonadonna, MPS
Director of Extra-​Corporeal Life
Support
Duke University Medical Center
NC, USA
Chapters 8,19
Karen Booth, FRCS C/​Th
Consultant Cardiac and Transplant
Surgeon
Department of Cardiothoracic
Surgery
Freeman Hospital
Newcastle, UK
Chapters 27,32
Brandi Bottiger, MD
Associate Professor of Anesthesia
Division of Cardiothoracic
Anesthesia and Critical Care
Duke University Medical Center
NC, USA
Chapter 37
Benjamin Bryner, MD
Co-​Director of Duke ECMO
Program and Assistant Professor
of Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapter 12
Anthony Castleberry, MD
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
University of Nebraska Medical
Center
NE, USA
Chapter 14
Pedro Catarino, FRCS C/​Th
Director of Heart and Lung
Transplantation and Mechanical
Circulatory Support and Consultant
Cardiac and Transplant Surgeon
Royal Papworth Hospital
Cambridge, UK
Chapter 28
Yuting P. Chiang, MD
Resident in Cardiothoracic Surgery
Columbia University Medical Center
NY, USA
Chapter 6
Stephen C. Clark, FRCS C/​Th
Director of Heart and Lung
Transplantation and Professor
of Cardiothoracic Surgery and
Cardiopulmonary Transplantation
Department of Cardiothoracic
Surgery
Freeman Hospital and Newcastle
University
Newcastle, UK
Chapter 25
Sylvia Costa, MD
Adjunct Assistant Professor of
Medicine
Division of Infectious Diseases
Duke University Medical Center
NC, USA
Chapter 21
Philip Curry, FRCS C/​Th, PhD
Clinical Director of Cardiothoracic
Surgery and Consultant Cardiac and
Transplant Surgeon
Department of Cardiothoracic
Surgery
Golden Jubilee National Hospital
Glasgow, UK
Chapters 7,11,13

Jonathan R. Dalzell, FRCP
Consultant Heart Failure
Cardiologist
Scottish National Advanced Heart
Failure Services
Golden Jubilee National Hospital
Glasgow, UK
Chapters 17,18
Mani A. Daneshmand, MD
Director of Heart and Lung
Transplantation and MCS Programs
and Associate Professor of Surgery
Division of Cardiothoracic Surgery
Emory University School of
Medicine
GA, USA
Chapter 6
John Dark, FRCS
Professor of Cardiothoracic
Surgery and Cardiopulmonary
Transplantation
Past President of ISHLT
Newcastle University
Newcastle, UK
Chapter 27
Adam D. DeVore, MD
Assistant Professor of Medicine
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 20
Julie Doberne, MD, PhD
Resident in Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapters 12,26
Hari Doshi, FRCS C/​Th
Consultant Cardiac and Transplant
Surgeon
Department of Cardiothoracic
Surgery
Golden Jubilee National Hospital
Glasgow, UK
Chapter 13
Contributors xxi
Kamrouz Ghadimi, MD
Associate Professor of
Anesthesiology
Division of Cardiothoracic
Anesthesia and Critical Care
Duke University Medical Center
NC, USA
Chapter 35
Igor Gosev, MD, PhD
Assistant Professor
Division of Cardiothoracic Surgery
University of Rochester Medical
Center
NY, USA
Chapter 5
John Haney, MD
Surgical Director of Lung
Transplantation and Assistant
Professor of Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapter 28
Matthew Hartwig, MD
Associate Professor of Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapters 26,29
Asif Hasan, FRCS C/​Th
Consultant Congenital Cardiac and
Transplant Surgeon
Children’s Heart Unit
Freeman Hospital
Newcastle, UK
Chapters 22.1,22.2,23
Nazish Hashmi, MD
Assistant Professor of Anesthesia
Division of Cardiothoracic
Anesthesia and Critical Care
Duke University Medical Center
NC, USA
Chapter 37
xxii Contributors
Jeffrey Javidfar, MD
Assistant Professor of Surgery and
Assistant Surgical Director of the
Lung Transplantation Program
Division of Cardiothoracic Surgery
Emory University School of Medicine
GA, USA
Chapter 8
Louise Kenny, FRCS C/​Th
Specialist Registrar in Congenital
Cardiac Surgery
Children’s Heart Unit
Freeman Hospital
Newcastle, UK
Chapters 22.2, 23
Maziar Khorsandi, FRCS C/​Th
(Managing editor)
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
University of Washington Medical
Center
WA, USA
Chapters 7,8,9,11
Alan J. Kirk, FRCS
Honorary Professor of Surgery
Consultant Thoracic Surgeon
Golden Jubilee National Hospital
and University of Glasgow
Glasgow, UK
Chapter 18
Jacob Klapper, MD
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapter 26
Antonios Kourliouros, FRCS
C/​Th, PhD
Consultant Cardiac Surgeon
Oxford Heart Centre
John Radcliffe Hospital
Oxford, UK
Chapter 4
Stephen Large, FRCS C/​Th
Consultant Cardiac and Transplant
Surgeon
Department of Cardiothoracic
Surgery
Royal Papworth Hospital
Cambridge, UK
Chapter 15
Rahul Loungani, MD
Cardiology Fellow
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 3
Michael W. Manning,
MD, PhD
Associate Professor of Anesthesia
Division of Cardiothoracic
Anesthesia and Critical Care
Duke University Medical Center
NC, USA
Chapter 35
Philip McCall, FRCA
Fellow in Cardiothoracic
Anaesthesia and Critical Care
Golden Jubilee National Hospital
Glasgow, UK
Chapter 36
Lynn McGugan, ACNP
Critical Care Nurse Practitioner
Duke University Medical Center
NC, USA
Chapter 19
Dominick Megna Jr, MD
Assistant Professor of Surgery
Surgical Director of Lung
Transplantation Program
Division of Cardiothoracic Surgery
Cedar Sinai Medical Center
CA, USA
Chapters 9,10
Simon Messer, MRCS, PhD
Registrar in Cardiothoracic Surgery
Department of Cardiothoracic
Surgery
Royal Papworth Hospital
Cambridge, UK
Chapter 15
 Contributors xxiii

Carmelo Milano, MD Alina Nicoara, MD

Professor of Surgery
Chief Section of Adult Cardiac
Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Michael Mulvihill, MD
Resident in Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapter 29
Jagan Murugachandran, MRCP
Registrar in Internal and Respiratory
Medicine
Specialty Registrar in Respiratory
Critical Care and General Internal
Medicine
Royal Papworth Hospital
Cambridge, UK
Chapter 31
Arun Nair, FRCP
Consultant in Respiratory Medicine
and Lung Transplantation
Department of Respiratory
Medicine and Lung Transplantation
Freeman Hospital
Newcastle, UK
Chapter 30
Sukumaran Nair, FRCS C/​Th
Consultant Cardiac and Transplant
Surgeon
Golden Jubilee National Hospital
Glasgow, UK
Chapters 7,11,17
Basil Nasir, FRCSC
Assistant Professor of Surgery
Division of Thoracic Surgery
Centre Hospitalier de l’Université
de Montréal
Montreal, Canada
Chapters 24,28
Mohamed Nassar, FRCS C/​Th
Consultant Congenital Cardiac and
Transplant Surgeon
Freeman Hospital
Newcastle, UK
Chapter 22.1
Associate Professor of Anesthesia
Division of Cardiothoracic
Anesthesia and Critical Care
Duke University Medical Center
NC, USA
Chapter 36
Yejide Odedina, MRCP
Specialty Registrar in Respiratory
and General Internal Medicine
Department of Respiratory and
Internal Medicine
Royal Papworth Hospital
Cambridge, UK
Chapter 31
Jasvir Parmar, FRCP, PhD
Consultant in Respiratory Medicine
Department of Lung
Transplantation
Royal Papworth Hospital
Cambridge, UK
Chapters 31,33
Chetan Patel, MD
Associate Professor of Medicine
Division of Cardiology
Duke University Medical Center
NC, USA
Chapters 3,12
Ed Peng, FRCS C/​Th
Consultant Cardiac Surgeon, Royal
Hospital
Children Glasgow and Golden
Jubilee National Hospital
Scotland, UK
Chapters 22.2, 22.3
Mihai Podgoreanu, MD
Chief of Division of Cardiothoracic
Anesthesia and Critical Care and
Associate Professor of Anesthesia
Duke University Medical Center
NC, USA
Chapter 37
Danny Ramzy, MD, PhD
Associate Professor of Surgery
Division of Cardiothoracic Surgery
Cedar Sinai Medical Center
CA, USA
Chapter 9
xxiv Contributors
John M. Reynolds, MD
Medical Director of Lung
Transplantation and Associate
Professor of Medicine
Division of Lung Transplantation,
Pulmonary and Critical Care
Duke University Medical Center
NC, USA
Chapter 24
Joseph G. Rogers, MD
Chief Medical Officer and Professor
of Medicine
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 1
Sebastian V. Rojas, MD
Co-​Director of Cardiac
Transplantation
Department of Cardiothoracic,
Transplantation and Vascular
Surgery
Hannover Medical School
Hannover, Germany
Chapter 14
Stuart D. Russell, MD
Director of Heart Failure and
Professor of Medicine
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 2
Marc D. Samsky, MD
Cardiology Fellow
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 1
Julie R. Samuel, FRCPath
Clinical Director of the Department
of Clinical Microbiology and
Consultant Clinical Microbiologist
Freeman Hospital
Newcastle, UK
Chapter 32
Jacob Schroder, MD
Director of Heart Transplantation
Program and Assistant Professor
of Surgery
Division of Cardiothoracic Surgery
Duke University Medical Center
NC, USA
Chapters 14,16,34
Sounok Sen, MD
Cardiology Fellow
Division of Cardiology
Duke University Medical Center
NC, USA
Chapter 20
Jigesh A. Shah, DO
Fellow in Abdominal Organ
Transplantation
Division of Abdominal
Transplantation
Duke University Medical Center
NC, USA
Chapter 34
Scott Silvestry, MD
Surgical Director of Thoracic
Transplantation and Associate
Professor of Surgery
Division of Cardiothoracic Surgery
Florida Hospital Transplant Institute
FL, USA
Chapter 5
Andrew Sinclair, FRCA
Director of Mechanical Circulatory
Support and Consultant in
Anaesthesia and Critical Care
Golden Jubilee National Hospital
Glasgow, UK
Chapters 17,36
Sanjeet A. Singh, MRCS, PhD
Clinical Fellow in Heart
Transplantation
Department of Cardiothoracic
Surgery
Golden Jubilee National Hospital
Glasgow, UK
Chapter 17
 Contributors xxv

Alison I. Smyth, MRCP Evelyn Watson, RN

Clinical Fellow in Heart Failure
Cardiology
Scottish National Advanced Heart
Failure Services
Golden Jubilee National Hospital
Glasgow, UK
Chapter 18
Steven Tsui, FRCS C/​Th
Clinical Director of Transplant
Services and Director of Mechanical
Circulatory Support
Consultant Cardiac and Transplant
Surgeon
Royal Papworth Hospital
Cambridge, UK
Chapters 15,33
Nathan Waldron, MD
Assistant Professor in Anaesthesia
and Critical Care
University of Colorado Health
Memorial Hospital Central
CO, USA
Chapter 29
Specialist Charge Nurse
Regional Transplant Unit
Freeman Hospital and Newcastle
University
Newcastle, UK
Chapter 19
Christopher White,
FRCSC, PhD
Heart Failure Surgeon
Assistant Professor of Surgery
Dalhousie University
New Brunswick Heart Center
NB, Canada
Chapter 16
Lorenzo Zaffiri, MD
Assistant Professor of Medicine
Division of Lung Transplantation,
Pulmonary and Critical Care
Duke University Medical Center
NC, USA
Chapter 30
xxvi
 xxvii

Abbreviations
ABOi AABO incompatible CNS central nervous system
ACC American College of COPD chronic obstructive pulmonary
Cardiology disease
ACE angiotensin-​converting enzyme CPB cardiopulmonary bypass
ACEi angiotensin-​converting enzyme CPR cardiopulmonary resuscitation
inhibitor CPX cardiopulmonary exercise
ACHD adult congenital heart disease CRT cardiac resynchronization
ACT activated clotting time therapy
ADHERE Acute Decompensated Heart CSF cerebrospinal fluid
Failure National Registry CVP central venous pressure
AHA American Heart Association CXR chest X-​ray
AL amyloid light chain DBD donation after brain death
AMR antibody-​mediated rejection DC direct current
Ao aorta DCD donation after
aPTT activated partial circulatory death
thromboplastin time DCM dilated cardiomyopathy
ARB angiotensin II receptor DLCO diffusion capacity of the lung
blocker for carbon monoxide
ARDS acute respiratory distress DPC distal perfusion cannula
syndrome
DSA donor-​specific antibody
ASD atrial septal defect
EACTS European Association for
ATG anti-​thymocyte globulin Cardio-​Thoracic Surgery
ATTR-​CM transthyretin amyloid EBV Epstein–​Barr virus
cardiomyopathy
ECG electrocardiogram
AV atrioventricular
ECLS extracorporeal life support
BAL bronchoalveolar lavage
ECMO extracorporeal membrane
BB beta blocker oxygenation
BiVAD biventricular assist device E-​CPR extracorporeal
BMI body mass index cardiopulmonary resuscitation
BNP B-​type natriuretic peptide EF ejection fraction
BOS bronchiolitis obliterans eGFR estimated glomerular
syndrome filtration rate
BSA body surface area ELSO Extracorporeal Life Support
BSD brainstem death Organization
BTT bridge to transplantation ESR erythrocyte sedimentation rate
CAD coronary artery disease EVLP ex vivo lung perfusion
CAV cardiac allograft vasculopathy FDA Food and Drug Administration
CDAD Clostridium difficile-​associated FEV1 forced expiratory volume in
diarrhoea 1 second
CF cystic fibrosis FiO2 fraction of inspired oxygen
CI cardiac index FVC forced vital capacity
CLAD chronic lung allograft GFR glomerular filtration rate
dysfunction GI gastrointestinal
CMV cytomegalovirus GTN glycerol trinitrate
CNI calcineurin inhibitor HB hepatitis B
xxviii Abbreviations

HBV hepatitis B virus LVEDP left ventricular end-​diastolic

HCV hepatitis C virus pressure
HF heart failure LVEF left ventricular ejection fraction
HFpEF heart failure with preserved LVH left ventricular hypertrophy
ejection fraction MAP mean arterial pressure
HFrEF heart failure with reduced MCS mechanical circulatory support
ejection fraction MELD Model for End-​Stage Liver
HFSS Heart Failure Survival Score Disease
HHV herpesvirus MFI mean fluorescent intensity
HIT heparin-​induced MMF mycophenolate mofetil
thrombocytopenia MR mitral regurgitation
HIV human immunodeficiency virus MRA mineralocorticoid receptor
HKTx heart–​kidney transplantation antagonist
HLA human leucocyte antigen MRI magnetic resonance imaging
HLTx heart–​lung transplantation MRSA methicillin-​resistant
HM HeartMate Staphylococcus aureus
HSV herpes simplex virus mTOR mechanistic target of
rapamycin
hTTR hereditary transthyretin
MV mitral valve
HZ herpes zoster
NAAT nucleic acid amplification
IA invasive aspergillosis testing
IABP intra-​aortic balloon pump/​ NICM non-​ischaemic
counterpulsation cardiomyopathy
ICD implantable cardioverter NO nitric oxide
defibrillator
NODAT new-​onset diabetes after
ICU intensive care unit transplantation
Ig immunoglobulin NRAD neutrophilic reversible allograft
IJ internal jugular dysfunction
IL-​2 interleukin-​2 NTM non-​tuberculous mycobacteria
IL2R interleukin-​2 receptor NT-​proBNP N-​terminal pro-​B type
IL2RA interleukin-​2 receptor natriuretic peptide
antagonist NYHA New York Heart Association
ILD interstitial lung disease OHT orthotopic heart
INR international normalized ratio transplantation
INTERMACS Interagency Registry for PA pulmonary artery
Mechanically Assisted PAC pulmonary artery catheter
Circulatory Support PaCO2 partial arterial pressure of
ISHLT International Society for Heart carbon dioxide
and Lung Transplant PaO2 partial arterial pressure
IV intravenous of oxygen
IVIG intravenous immunoglobulin PCCS post-​cardiotomy
LA left atrial/​atrium cardiogenic shock
LAA left atrial appendage PCO2 partial pressure of carbon
LAS lung allocation score dioxide
LKTx lung–​kidney transplantation PCR polymerase chain reaction
LLTx lung–​liver transplantation PCWP pulmonary capillary wedge
pressure
LV left ventricular/​ventricle
PEEP positive end-​expiratory
LVAD left ventricular assist device pressure
LVEDD left ventricular end-​diastolic PFO patent foramen ovale
diameter
PFT pulmonary function testing
PGD primary graft dysfunction
 Abbreviations xxix

PH pulmonary hypertension SVR systemic vascular resistance

PJP Pneumocystis jirovecii TAH total artificial heart
pneumonia TAVR transcatheter aortic valve
PLE protein-losing enteropathy replacement
PO per os (orally) TBBX transbronchial biopsy
PO2 partial pressure of oxygen TEG thromboelastography
PRA panel-​reactive antibody TLC total lung capacity
PT physical therapy TMP–​SMX trimethoprim–​
PTLD post-​transplant sulfamethoxazole
lymphoproliferative disorder TOE transoesophageal
PVR pulmonary vascular resistance echocardiography/​
echocardiogram
RA right atrial/​atrium
TR tricuspid regurgitation
RAA right atrial appendage
TTE transthoracic
RAAS renin–​angiotensin–​ echocardiography
aldosterone system
TTR transthyretin
RAS restrictive allograft syndrome
UFH unfractionated heparin
rATG rabbit anti-​thymocyte globulin
UNOS United Network for Organ
RCM restrictive cardiomyopathy Sharing
rpm revolutions per minute V/​Q ventilation/​perfusion
RV right ventricular/​ventricle VA venoarterial
RVAD right ventricular assist device VAD ventricular assist device
RVEDP right ventricular end-​diastolic VAV venoarteriovenous
pressure
VO2max maximal oxygen
RVEF right ventricular ejection consumption
fraction
VSD ventricular septal defect
SHFM Seattle Heart Failure Model
VV venovenous
SOT solid organ transplant
VZV varicella zoster virus
SVC superior vena cava
WHO World Health Organization
SvO2 mixed venous oxygen
saturation wtTTR wild-​type transthyretin
Another random document with
no related content on Scribd:
 Fig. 488.—Saxifraga granulata. Longitudinal section
of flower.
The following genera are allied to the Saxifragaceæ:—
1. Parnassia (about 14 species; P. palustris, Grass of Parnassus).
The flower is slightly perigynous, and has S5, P5, 5 fertile sepal-
stamens, and 5 petal-stamens, which are developed as barren
staminodes, palmately-lobed, and (3–) 4 carpels united in a 1-locular
ovary with (3–) 4 parietal placentæ. Capsule.—Protandrous. The flower
has a slightly oblique plane of symmetry, which is especially shown during its
development and in the order of sequence in which the anthers dehisce: originally
they lie closely round the gynœceum; the anthers dehisce extrorsely, first the one
which is placed opposite the most external sepal (the 2/5 arrangement is very
distinct in the calyx), the filament elongating so that the anther lies over the ovary,
and this is followed successively by the 4 others in a zig-zag line; the filaments
bend backwards after the pollen is shed and the anthers drop off, and the stigmas
are not developed until this is completed. The barren stamens are palmately
divided into an uneven number (7, 9, 11) of lobes, tapering from the centre towards
the edge, and bearing apparently glandular tips; their gland-like appearance is
supposed to allure flies to visit the flower, or they may act as a kind of fence which
compels the insects to enter the flower in a certain way, and thus effect pollination;
the honey is secreted on their inner side, and not by the gland-like tips.
 Fig. 489.—Portion of Cephalotus follicularis: k
pitcher-like leaf with thick corrugated edge (m) and lid
(l); b foliage-leaf of the ordinary form.]
2. Adoxa moschatellina (Moschatel). This is a perennial, creeping
herb; the horizontal rhizome has an unlimited growth, and bears, in a
scattered arrangement, both foliage-leaves, and white, fleshy scale-
leaves. The aerial stem bears 2 opposite foliage-leaves and a
capitate inflorescence of 5 flowers, 4 placed laterally (in opposite
pairs) and 1 terminally. The flower is semi-epigynous, the calyx
gamosepalous, corolla absent. The stamens are divided to the base,
so that each filament bears a bilocular anther. The style is free,
deeply cleft. The terminal flower has 2 bracteoles, 4 sepals, 4
stamens, cleft to the base, and a 4-locular ovary. The bracts of the
lateral flowers are displaced on the flower-stalk, as in
Chrysosplenium, and united with the 2 bracteoles into a kind of 3-
leaved involucre; these flowers have 5 sepals, 5 split stamens with
2-locular anthers, and a 5-locular ovary. 1 pendulous ovule in each
loculus. Fruit a drupe, green-coloured, with 1–5 stones.—This plant,
which would perhaps be best placed in a special order, has also
been classed with the Araliaceæ and Caprifoliaceæ.
 The following are also allied to this order: Escalloniaceæ (arborescent plants
with simple, scattered, leathery leaves), Cunoniaceæ (arborescent with opposite
leaves), Cephalotaceæ (with pitcher-like, insect-catching leaves; Australia; Fig.
489) and Francoaceæ. These have respectively 85, 107, 1 and 3 species.

Figs. 490–492.—Ribes rubrum.

Fig. 490.—Floral diagram.

Fig. 491.—Flower in longitudinal section.

 Fig. 492.—Seeds in
longitudinal section.
Order 3. Ribesiaceæ (Currants). 5-stamened Saxifragaceæ with
epigynous flowers.—Moderately sized shrubs with scattered, stalked
and palminerved, and generally palmilobed leaves, with a large leaf-
sheath. The flowers (Figs. 490, 491), most frequently borne in
racemes, are regular, epigynous, and have often, above the ovary, a
cup- or bell-shaped, or tubular prolongation of the receptacle, on
which the sepals, petals and stamens are situated; they have 5
sepals (often large, coloured), 5 small, free petals, only 5 stamens
(opposite the sepals) and a 2-carpellate gynœceum with a unilocular
ovary and 2 parietal placentæ bearing many ovules. The fruit is a
berry, whose seeds have a fleshy and juicy outer covering (Fig. 492).
In some species, for example Ribes grossularia, there is found an unbranched, or
a 3–5-branched spine, very closely resembling the spiny leaves of the Berberis,
but which, however, are emergences springing from the base of the petiole. Ribes
has two kinds of branches: long-branches and dwarf-branches, the latter alone
bearing the flowers.—Ribes (Figs. 490–492). The blades of the leaf are
folded or rolled together in vernation. R. alpinum is diœcious.
75 species; especially from the N. Temp. regions (especially N. Am.).—The
receptacle secretes honey on its inner surface. The Gooseberry-flower is slightly
protandrous, others are homogamous; insect-and self-pollination are found. The
following are fruit bushes: R. nigrum (Black Currant), R. rubrum (Red Currant),
R. grossularia (Gooseberry), originating in Northern Europe and Asia.
Ornamental bushes: the North American R. aureum (Golden Currant) and R.
sanguineum (Blood-red Currant), etc.

Fig. 493.—Deutzia crenata.

Longitudinal section of flower.
Order 4. Hydrangeaceæ. Shrubs, with simple, opposite leaves, without
stipules; flowers generally epigynous, 4–5-merous (Fig. 493).—Hydrangea (H.
hortensia, etc.). Shrubs from N. Am. and E. Asia; corolla often valvate. The
inflorescence, as in the case of the inflorescence of Viburnum opulus (Guelder
Rose), has often irregular, large, but barren flowers at the circumference, whilst the
others are much smaller, regular and ☿; the barren flowers are mostly 4-merous; in
these cases it is the calyx which is large and petaloid, while the other parts of the
flower are more or less suppressed. The branches of the inflorescence appear to
be partially devoid of floral-leaves, since they are displaced upon the main axis.—
Philadelphus; racemes (with terminal flower), sepals 4 (valvate), petals 4 (twisted),
stamens many, and carpels 4 (opposite the petals), forming a 4-locular ovary. The
numerous stamens (20–30) occur by the splitting of the sepal-stamens and are
often therefore placed in distinct bundles. Fruit a capsule. Ph. coronaria (Syringa,
Mock Orange-blossom), from S. Eur., is a common ornamental shrub, as also is
Deutzia (Fig. 493) from N. Am. and E. Asia. The latter has S5, P5, A5 + 5, G3.—
About 70 species.
Order 5 (?). Pittosporaceæ. This order has its home especially in Australia (90
species). The flower has S5, P5, A5 (episepalous), G2 (3–5), most frequently a
unilocular ovary with many ovules in 2 rows, borne on 2 parietal placentæ, or a
bilocular ovary. Some have berries, others capsules. Pittosporum, Citriobatus,
Sollya, Billardiera.
Order 6. Hamamelidaceæ. Flowers more or less epigynous, with S4, P0 or 4, 4
fertile sepal-stamens, and 4 barren petal-stamens, bilocular ovary with 1–2 ovules
in each loculus. Fruit a capsule. Hamamelis: one species in Japan and one in N.
Am. Fothergilla. Liquidambar: monœcious; flowers in capitula or spikes; ♂-flowers
without perianth, stamens indefinite; ♀-flower: slight perianth, 2-locular ovary with
many ovules. Officinal: “Styrax-balsam,” which is obtained by boiling the bark of
Liq. orientalis, from Asia Minor. Liquidambar and Parrotia are found as fossils in
the Upper Oligocene; Hamamelis perhaps in the Chalk.
Finally two orders with very reduced flowers are included in this family.
Order 7. Platanaceæ. Trees, with large, scattered, palminerved and lobed
leaves, and ochreate stipules; the buds are concealed in a hollow at the base of
the petiole. The bark falls off in large scales. ♂ -and ♀ -flowers (monœcious) in
crowded, spherical inflorescences which are placed at wide intervals on a terminal,
thin, and pendulous axis. The flowers have an insignificant calyx and corolla; the
♂-flower has few stamens; ♀-flower, perigynous, with 4 free carpels, 1 pendulous,
orthotropous ovule in each. Fruit a nut; endosperm absent. 5 species; frequently
grown in avenues and parks. P. occidentalis (N. Am.); P. orientalis (W. Asia.).
Order 8. Podostemaceæ. Aquatic plants, especially in swiftly running water,
with somewhat of an Alga-like, Moss-like, or thalloid appearance; they show
themselves in many ways to be adapted to their mode of life and situations (having
a dorsiventral creeping stem, the flowers sunk in hollows, a formation of haptera
upon the roots, and thalloid assimilating roots and thalloid stems, etc.). Tropical;
100 species.

Family 20. Rosifloræ.

The leaves are scattered, stipulate, or have at least a well
developed sheath, which is generally prolonged on each side into a
free portion (“adnate stipules”). The flowers are regular, perigynous
or epigynous. Calyx and corolla 5 (-4)-merous with the usual
position. The corolla is always polypetalous. The stamens are
present in very varying numbers (5–∞) and position, but always
placed in 5-or 10-merous whorls; they are frequently 20 in 3 whorls
(10 + 5 + 5; see Figs. 494, 502, 505); the nearer they are placed to
the circumference, the longer they are; they are generally incurved in
the bud, or even rolled up. The number of the carpels is from 1–∞; in
most cases all are individually free (syncarp), and when they are
united it is in every case with the ovaries only, whilst the styles
remain more or less free (Pomaceæ, species of Spiræa). The seeds
have a straight embryo, and usually no endosperm.
The perianth and stamens are most frequently perigynous on the edge of the
widened receptacle; its form varies between a flat cupule and a long tube or a cup
(Figs. 495, 496, 498, 499, 500); the carpels are situated on its base or inner
surface, in some instances on a central conical elongation of the floral axis (Fig.
496). The carpels in Pomaceæ also unite more or less with the hollow receptacle,
or this grows in and fills up the space between the carpels, so that a more or less
epigynous flower is formed (Fig. 504).—The following numbers of stamens occur:
5, 10 (in 1 whorl), 15 (10 + 5), 20 (10 + 5 + 5), 25 (10 + 10 + 5), 30-50 (in 10-
merous whorls)—compare the diagrams. The theoretical explanation of this
relation of the 10-merous whorls and their alternation with the 5-merous whorls is
not definitely determined; a splitting of the members of the 5-merous whorls may
be supposed, but the development shows no indication of this, and it is not
supported in any other way. Several genera have “gynobasic” styles, that is, the
style springs from the base of the ovary (Fig. 497 A, B).
 The Rosifloræ are on one side closely related to the Saxifragaceæ (especially
through Spiræa) from which it is difficult to separate them, and to the Myrtifloræ;
on the other side they are allied, through the Mimosaceæ with the large number of
stamens, and through the Amygdalaceæ with its single carpel, to the Leguminosæ.
The family begins with forms which have many-seeded follicles, and passes on the
one side to forms with nuts and drupes in perigynous flowers, and on the other
side to the Pomaceæ.

Order 1. Rosaceæ. Herbs or shrubs, generally with compound

leaves and persistent (adnate) stipules, flower perigynous,
gynœceum formed of many free (therefore oblique) carpels,
syncarps with fruitlets of various kinds. The exceptions are noted
under the genera.

Fig. 494.—Diagram of Comarum

palustre.
 Fig. 495.—Flower of Spiræa lanceolata.
1. Spiræeæ (Fig. 495) has 2–many ovules in each ovary, while in
the other groups there is generally only 1, and never more than 2
ovules in each loculus. There are generally 5 cyclic carpels and the
fruit is 5 follicles, which are not enclosed by the receptacle. The
majority are shrubs. Stipules are often wanting.—Spiræa (Meadow-
Sweet). The flowers are generally borne in richly flowered
inflorescences of various forms. The carpels, in some species, unite
together and form a simple gynœceum with free styles (an approach
to the Pomaceæ).—Closely allied to Spiræa are the East Asiatic shrubs: Kerria
japonica, which has solitary flowers, in this country nearly always double (the fruit
a nut), and Rhodotypos kerrioides which has opposite leaves, a remarkable
feature among the Rosifloræ; it has a 4-merous flower, a well developed disc
inside the andrœcium, and a drupe. Closely allied also is Gillenia (N. Am.) differing
chiefly in the ascending ovules, Spiræa having pendulous ovules, and a more
tubular receptacle.
The groups Quillajeæ and Neuradeæ form a transition from Spiræa to
Pomaceæ. In the first group, which contains only trees or shrubs with generally
simple leaves, the carpels are either free or united (into a capsule); in the second
the receptacle unites with the carpels, which are themselves often united together;
in this case, too, the fruit is a capsule. Quillaja (S. Am.); Exochorda (China).
 2. Potentilleæ (Figs. 494, 496, 497). The flower has an
“epicalyx” (Fig. 494 C) alternating with the sepals and formed by
their stipules which are united in pairs, and hence its leaves are
often more or less deeply bifid. The receptacle is cupular and often
quite insignificant. The sepals are valvate in the bud. The large
number of fruitlets are achenes, borne on a well-developed convex
portion of the receptacle (the Ranunculeæ resemble the Potentilleæ, but
have no epicalyx, no enlarged receptacle, and spirally-placed stamens). Most of
the species are herbs with dichasial inflorescences, often arranged
in racemes.—Potentilla (Cinquefoil). The achenes are borne on a
dry, hairy receptacle; the style is situated towards the apex of the
ovary, and is not prolonged after flowering. Herbs with digitate, in
some, however, pinnate leaves, and generally yellow flowers.—
Comarum (Fig. 494) (Marsh Cinquefoil) forms, by its fleshy-spongy
receptacle, a transition to the next genus.—Fragaria (Strawberry)
(Fig. 496). The receptacle becomes finally fleshy, coloured, and falls
off (biologically it is a berry); the numerous fruitlets (drupes with thin
pericarp) have basal styles (Fig. 497); leaves trifoliate; long, creeping
runners.—Geum (Avens) has a terminal style which after flowering
elongates into a long beak, with the apex (after the uppermost part
has been thrown off) bent back into a hook, thus furnishing a means
of distribution for the fruits. Leaves pinnate.—Dryas comprises 3 Arctic or
Alpine species with simple leaves and solitary flowers, the calyx and corolla 8–9-
merous, the fruit resembles that of Geum, but the styles become still longer and
feather-like (a flying apparatus).
 Figs. 496, 497.—Fragaria vesca.

Fig. 496.—Longitudinal section of flower.

Fig. 497.—A carpel, entire,

and in longitudinal section.

3. Rubeæ. Rubus (Bramble) has the same form of receptacle as

the Potentilleæ, but no epicalyx; the fruitlets are drupes, not
enclosed by the persistent calyx. Most frequently shrubs or
undershrubs with prickles (emergences), glandular bristles and
compound leaves. In the Raspberry (R. idæus) the fruitlets unite
together and detach themselves from the receptacle.
 4. Roseæ. Rosa; the receptacle is hollow, ovoid and contracted
beneath the insertion of the calyx (Fig. 498), ultimately fleshy and
coloured; it encloses a large number of fruitlets which are achenes
as hard as stones (“hip,” biologically a berry).—Shrubs with
imparipinnate leaves and adnate stipules. The sepals show clearly the
order of their development (a divergence of 2/5), the two outer ones on both sides
are lobed, the third one on one side only, and the two last, whose edges are
covered by the others, are not lobed at all. Prickles (emergences) are generally
present and in some species are placed in regular order, being found immediately
below each leaf (usually two) although at somewhat varying heights.

Fig. 498.—Longitudinal section of flower of Rosa.

 Figs. 499, 500.—Agrimonia eupatoria.

Fig. 499.—Flower in longitudinal section.

Fig. 500.—Fruit and receptacle in

longitudinal section.
 5. Agrimonieæ. The receptacle is more or less cup- or bell-
shaped, and almost closed at the mouth; it is persistent and
envelopes the nut-like fruitlets, but is dry, and in some species hard,
the fruitlets being firmly attached to it. In biological connection with
this the number of the carpels is generally only 1 or 2, and the whole
becomes a false nut (Fig. 500). Herbs.—Agrimonia (Agrimony; Figs.
499, 500); the perianth is 5-merous, stamens 5–20. The receptacle
bears externally, on the upper surface, a number of hooked bristles
which serve as a means of distribution for the 1–2 achenes which
are enclosed in it, and hence the entire flower finally falls off. The
inflorescence is a long upright raceme. These bristles are arranged in
whorls of 5 and 10, of which the uppermost alternate with the sepals.—
Alchemilla (Ladies-mantle; Fig. 501) has 8 green perianth-leaves in
two whorls (some authorities consider the four outer as an epicalyx,
and the flower therefore apetalous), and 4 stamens alternating with
the innermost whorl. There is only one carpel with a basal style and
capitate stigma. The flowers are small and greenish, the filaments
jointed. The anthers open by one extrorse cleft. The leaf-sheath
entirely envelops the stem; the leaves are palminerved. A. aphanes
has often only 1–2 stamens. The following genera, with 4-merous flowers
borne in short spikes or capitula, are allied to this group. Sanguisorba has
entomophilous, ☿-flowers with 4(-20) stamens, 1 carpel; stigma papillose.—
Poterium; spike or capitulum, the uppermost flowers are ♀, the lowermost ♂, and
some intermediate ones ☿ (the order of opening is not always centripetal); S4, P0,
A20–30, G2, the long styles having brush-like stigmas (wind-pollination). Leaves
imparipinnate.
 Fig. 501.—Flower of Alchemilla in longitudinal section.
Pollination. A yellow ring on the inner side of the receptacle, inside the
stamens, serves as a nectary when any honey is formed; this, for instance, is not
the case in Rosa, Agrimonia, Spiræa ulmaria, S. filipendula, S. aruncus, etc., to
which the insects (especially flies and bees) are allured by the quantity of pollen.
Homogamy and slight protogyny are frequent, in many instances self-pollination
also is finally possible. Poterium, with the long-haired stigma, is wind-pollinated.—
About 550 (1100?) species, especially in northern temperate regions.—Uses.
Officinal: the petals of Rosa centifolia and gallica, the fruits of the Raspberry
(Rubus idæus), the rhizome of Geum urbanum, the flowers of the Koso-tree
(Hagenia abyssinica or Brayera anthelmintica).—The bark of Quillaja saponaria
(Chili) is used as soap and contains saponin. “Attar of Roses” from Rosa
damascena, centifolia and other species, especially from the southern slopes of
the Balkans. Many species and varieties of Roses are ornamental plants: from S.
Europe, Rosa lutea (the Yellow Rose), R. gallica (the French Rose) and R.
rubrifolia; from W. Asia, R. centifolia, of which the Moss Roses (R. muscosa and
cristata) are varieties, and R. damascena; from India and N. Africa, R. moschata
(the Musk Rose); from China, R. indica (Tea Rose) etc., besides the native species
and the varieties which have been derived from them. In addition, Kerria japonica,
species of Potentilla, Rubus odoratus from N. Am., and many species of Spiræa
from South-eastern Europe and N. Am. Esculent: the “hips” of R. mollissima, R.
pomifera, etc.; the fruits of Rubus-species: Raspberry (R. idæus), Cloudberry (R.
chamæmorus), Blackberry (R. fruticosus), etc.; of Fragaria-species (F. vesca,
collina, grandiflora, etc).
 Order 2. Amygdalaceæ. Trees or shrubs with rosaceous flowers;
leaves simple with caducous stipules; a regular, perigynous flower,
the receptacle being partly thrown off by a circular slit; sepals 5,
petals 5, stamens 20–30; gynœceum simple, formed of 1 carpel
(hence oblique, Fig. 502), with terminal style and 2 pendulous
ovules, ripening into a drupe (Fig. 503).—The leaves are
penninerved and frequently have glands on the stalks and edges;
thorns (modified branches) often occur, i.e. dwarf-branches, which,
after producing a few leaves, terminate their growth in a thorn (e.g.
Prunus spinosa). The vernation of the foliage-leaves varies in the different
genera; in the Almond, Peach, Cherry, and Bird-Cherry they are folded; in the
Apricot, Plum, Sloe and Bullace, rolled together. In some the flowers unfold before
the leaves (Amygdalus, Armeniaca). That the gynœceum is formed of 1 carpel is
evident in this as in other instances (e.g. in the Leguminosæ, which are closely
related to this order), from the fact that the carpel is oblique, and has only one
plane of symmetry, and similarly in the fruit there is a longitudinal groove on one
side which indicates the ventral suture. It is only exceptionally that both ovules are
developed. In abnormal instances more than 1 carpel is developed.

Fig. 502.—Diagram of Prunus

virginiana.
 A. Fruit hairy: Amygdalus (A. communis, Almond-tree) has a dry
pulp which is detached irregularly, when ripe, from the wrinkled,
grooved, ovoid and somewhat compressed stone.—Persica (P.
vulgaris, Peach-tree) differs from the Almond in having a juicy pulp,
not detachable from the stone, which is deeply grooved and has pits
in the grooves (Fig. 503). (The name of the genus is derived from Persia,
though it is a native of China.).—Armeniaca (A. vulgaris, Apricot) has a
hairy, velvety fruit, but the stone is smooth and has two ribs along
one of the edges; the pulp is juicy. (The generic name has been given on
the incorrect assumption that it was a native of Armenia; its home is China.)

Fig. 503.—Fruit of the Peach. The pulp is

cut through so that the stone is visible.
B. Fruit glabrous (i.e. without hairs): Prunus (Plum) has a
glabrous fruit with bluish bloom; the stone is compressed, smooth or
wrinkled. The flowers are borne solitarily or in couples, and open
before or at the same time as the leaves; they are borne on shoots
without foliage-leaves.—Cerasus (Cherry) has a glabrous, spherical
fruit, without bloom, and a spherical stone. The flowers are situated
in 2–many-flowered umbels or racemes, and open at the same time
as the leaves or a little before them. Long-stalked flowers in umbels are
found in C. avium (Wild Cherry), C. vulgaris (the cultivated Cherry, from Western
Asia); racemes at the apex of leaf-bearing branches and small spherical fruits are
found in C. padus (Bird Cherry), C. virginiana, C. laurocerasus (Cherry-laurel), C.
mahaleb.
Pollination. Prunus spinosa (Sloe, Blackthorn) is protogynous, but the
stamens are developed before the stigma withers. Honey is secreted by the
receptacle. Cerasus padus (Bird-Cherry) agrees in some measure with P. spinosa.
In the flowers of the Plum and Cherry the stamens and stigma are developed
simultaneously and self pollination seems general; the stigma, however, overtops
the inner stamens and thus promotes cross-pollination.—Distribution. 114
species in the N. Temp, zone; few in the warmer regions; the majority from W.
Asia. C. vulgaris, from the regions of the Caspian; Prunus spinosa, insititia
(Bullace), domestica (Plum, from the Caucasus, Persia).—Uses, principally as
fruit-trees: Cherry, Plum, Apricot, etc.; “Almonds” are the seeds of Amygdalus
communis (W. Mediterranean), “bitter,” “sweet,” and “shell” almonds are from
different varieties, the latter being remarkable for the thin, brittle stone. In the
majority of species and in almost all parts of the plant (especially the bark, seed
and leaves) is found the glycoside, amygdalin, which forms prussic acid. Many
form gum, and the seeds have fatty oils (“Almond oil”). Officinal: the seeds and
oil of Amygdalus communis, and the fruit of the Cherry; in other countries also the
leaves of C. laurocerasus.—The stems of Cerasus mahaleb are used for pipes.
Ornamental Shrubs: Amygdalus nana, Cerasus laurocerasus.
Order 3. Chrysobalanaceæ. Tropical Amygdalaceæ with zygomorphic flower
and gynobasic style. 200 species; especially Am. and Asia. Chrysobalanus icaco
(Cocoa-plum) is cultivated on account of its fruit (Am.)
Order 4. Pomaceæ. Trees and shrubs, most frequently with
simple leaves and caducous stipules. The flowers (Fig. 505) have 5
sepals, 5 petals and generally 20 stamens (10 + 5 + 5, or 10 + 10 +
5). There are from 1–5 carpels, which unite entirely or to some
extent with each other, and with the hollow, fleshy receptacle (the
flower becoming epigynous), (Figs. 505, 506, 507). The carpels are
nearly always free on the ventral sutures, rarely free at the sides
also. The whole outer portion of the fruit becomes fleshy, but the
portions of the pericarp surrounding the loculi (endocarp) are most
frequently formed of sclerenchymatous cells, and are more or less
firm (the “core”). The nature of the fruit varies, according to the
thickness and hardness of the endocarp, being either a “berry” or a
“drupe” (see A and B). When the endocarp is thin and parchment-
like, the fruit has the characteristics of a berry, each of the 5 loculi
generally present containing several seeds; but when this is hard the
fruit resembles a drupe, only one seed is developed in each loculus,
and the number of the loculi is reduced to one or two. There are
nearly always 2 ovules in the loculi of the ovary, but in Cydonia there
are a large number in 2 rows. In the genera which have stones, only
one seed is developed in each stone. The genera are distinguished
mainly in accordance with the kind of fruit and the number of ovules
and seeds.

Fig. 504.—Longitudinal and transverse section through the flowers of

A, B Cotoneaster; C Cydonia; D Malus communis; E Raphiolepis; F
Cydonia; G Mespilus.
 Fig. 505.—Floral diagram of Mespilus
germanica.
A. Sorbeæ. The endocarp is parchment-like or papery
(drupe, with thin stone or berry).
1. Pyrus and Cydonia; carpels completely embedded in the cup-
like receptacle, styles always free.—Pyrus: the fruit is glabrous, and
has only a small calyx, withering or deciduous, and a 5-locular ovary
with at most 2 ascending ovules in each loculus (Fig. 504 D). The
large flowers are situated in few-flowered umbels or corymbs. P.
communis (Pear; free styles, Fig. 507; it has the well-known pear-shaped fruit; the
core is reduced to several groups of sclerenchymatous cells embedded in the
pulp, the leaf-stalk is as long as the blade).—Cydonia (Quince) has a hairy
fruit with many seeds in 2 rows in each loculus of the endocarp
(Figs. 504 C, F; 506); the testa of these seeds is mucilaginous. C.
vulgaris, large, terminal flowers on lateral branches, and large leaf-
like, persistent sepals.