Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

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.

Atrioventricular valve (AVV) disease remains a challenge in the management of patients with congenital heart disease, particularly those with single ventricle palliation. Within this group, atrioventricular valve (AVV) disease remains the Achilles heel of long-term successful palliation. In recent years we have learned how AVV pathology is detrimental to late survival, as well as how challenging it can be to obtain a competent and durable repair. In this expert review we outline strategies for AVV repair depending on AVV morphology: mitral, tricuspid, or common atrioventricular valve. Given the broad scope of AVV pathology, a large number of tools are needed in a congenital cardiac surgeon's armamentarium to successfully treat these patients. Many of these techniques have been successfully employed in patients with biventricular physiology, but can have applicability to those with single ventricle palliation.

Pleural tent is a procedure performed after upper lobectomies or lung volume reduction surgery to minimize the residual apical pleural space and favor pleura-pleura apposition. The final aim is to reduce the occurrence of air leak. This article describes the step-by-step technique to create a pleural tent after a videothoracoscopic upper lobectomy.

It is crucial to have an adequate-size unobstructed branch pulmonary artery architecture to achieve an ideal cavopulmonary circulation. Branch pulmonary artery distortion, stenosis, or hypoplasia is a common problem following the stage I Norwood procedure for infants with hypoplastic left heart syndrome regardless of the shunt type. This technical review describes the surgical principle and techniques of the extensive hilum to hilum branch pulmonary artery reconstruction at the time of stage II palliation, bidirectional cavopulmonary shunt in infants with hypoplastic left heart syndrome.

Technical aspects of aortic arch replacement have evolved over the years with significant focus on reducing the risk of operative morbidity and mortality. Recent developments in surgical methods relate to optimizing strategies for neuroprotection, distal organ perfusion and myocardial protection. We describe the branch-first technique for aortic arch replacement using a trifurcation graft with a side perfusion port (TAPP). It simplifies the delivery of continuous antegrade cerebral perfusion, and takes advantage of intracranial and extracranial networks to augment contralateral cerebral perfusion. Consequently, it allows for moderate levels of hypothermia and avoids distal circulatory arrest in many cases. In cases where distal circulatory arrest is required, it affords a longer safe duration of distal arrest and allows aortic pathology to be completely and meticulously corrected without time pressures.

Optimizing Fontan blood flow dynamics is essential to attain the best early and late outcomes after the Fontan procedure. Although the extracardiac conduit is the most favored variant, recent studies have suggested it may not always carry the best outcomes. The apparent simplicity of the procedure may mask some of the technical nuances that need to be considered and addressed at the time of operation. We list the common technical pitfalls that may impact the outcomes and our recommendations for addressing them.