Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

Surgical mitral valve repair has been the gold standard treatment for severe degenerative mitral regurgitation. However, a segment of patient population is considered too high risk for surgery because of their age and/or comorbidities.Catheter-based interventions have been developed during the last decade to address mitral regurgitation in high surgical risk patients. MitraClip System (Abbott Vascular, Santa Clara, CA, USA) is FDA approved in high risk patients with primary or secondary mitral regurgitation who meet certain criteria. This article touches briefly on indications for transcatheter edge to edge mitral valve repair (TEER) and focuses on describing procedural steps to perform TEER usig MitraClip device. These steps include preoperative assessment and planning using TEE images, transseptal access to mitral valve, introducing transseptal sheath, steerable guide catheter (SGC), and clip delivery system (CDS), crossing the mitral valve, grasping the leaflets in desired location, and deployment. Procedural steps are also demonstrated in a brief video.

Median sternotomy provides standard access in cardiac surgery. Sternal closure traditionally involves use of stainless steel wires with satisfactory results. Fixation of sternum using titanium plates with screws has been used in some institutions over the last two decades. This technique uses sternal wires in combination with a rigid plate fixation system. The wires are passed at the manubrium and xiphoid to help with approximation, while plates are used to fix the body of the sternum. The screws are passed through the outer table and penetrate the inner table of the sternum. There is increasing evidence to suggest that rigid plate fixation provides better mechanical stability of sternum; which seems to translate to less post-operative pain; better healing of sternum; lower incidence of deep sternal wound infection and sternal non-union. This approach is particularly useful in patients who have multiple risk factors predisposing them to post-operative sternal complications.

Aortic valve disease in children presents a considerable surgical challenge. When repair is not feasible, the Ross procedure represents the best option for replacement as it allows growth and does not require anticoagulation. However, there is a risk of progressive autograft dilatation, and eventual failure of the autograft with severe regurgitation. Autograft stabilization has proven beneficial in adults but has not been widely adopted in children undergoing the Ross procedure. We present a series of techniques for autograft stabilization which can be used at different stages of development, from infants to fully grown adolescents.

While the classical 1-stage Norwood procedure is still performed, there are several types of “hybrid” procedures for the management of hypoplastic left heart syndrome. These hybrid approaches consist of bilateral pulmonary artery banding with ductal stenting or prostaglandin infusion as the first-stage palliation, followed by a second-stage Norwood procedure or comprehensive stage II procedure. Since 2012, we have adopted a rapid 2-stage Norwood procedure as a routine strategy, where bilateral pulmonary artery banding is performed within 5 days of age with balloon atrial septectomy, if needed, before the development of hemodynamic instability. The second-stage Norwood procedure is performed within 1 month of age. The arterial duct is kept open by continuing prostaglandin administration. In addition, an important improvement of our Norwood procedure is the use of an auto-pericardial patch fixed on an arch-shaped metal mold. The pericardium is wrapped around the lesser curvature of the mold and treated with 0.6% glutaraldehyde for 15 min. This makes it easier to imagine the final shape of the arch and helps to enlarge the retroaortic space significantly, which could reduce the risk of bronchus or central pulmonary artery stenosis and facilitate hemostasis. These developments in strategy and procedure could improve our surgical results.

Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA), aiming to replace the whole length of the diseased distal aorta while protecting the spinal cord and visceral organs to limit ischemia-related complications. This surgery carries significant risks, including death, paraplegia, renal failure requiring permanent dialysis and respiratory complications leading to prolonged ICU stay, but these still outweigh the natural history of TAAA with conservative treatment. We describe in detail our current approach to open extent II TAAA repair by a step-by-step illustration of the technique and the surgical adjuncts. We routinely use left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor-evoked potentials (MEPs), cerebral, paraspinal and lower limbs oxygen saturations by near-infrared spectrometry as well as selective visceral perfusion via the coeliac, superior mesenteric and renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft and when possible and we selectively reattach one or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in absence of a significant reduction on the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft. Favorable early outcomes and a durable repair can be achieved at experienced high-volume centers, with standardized pre-operative selection and multidisciplinary team based intraoperative and postoperative management of these patients.