Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

The closure of Swiss-cheese multiple ventricular septal defects remains a difficult technical challenge and it is associated with increased mortality. Recently, the felt sandwich technique has been widely used to close muscular ventricular septal defects because the technique is simple, safe, effective, and reproducible. This technique may be useful, especially in complex cases, because it does not require prolonged surgical time. However, the use of numerous felt patches may disturb the movement of interventricular septum and cause cardiac dysfunction in infants. To avoid postoperative cardiac dysfunction, our current strategy is implemented to close muscular ventricular septal defects directly as much as possible. When the ventricular septal defect is considered unsuitable for direct closure, the felt sandwich technique is a useful tool that can be applied as needed by surgeons.

We describe an effective and practical approach for concomitant ablation that we use in 100% of mitral surgery patients with a history of atrial fibrillation. There are 3 steps. First the left atrial appendage is closed with a Clip with is highly effective and electrically isolates it. Second, 3 cryoablation lines are used to recreate the key Cox-Maze III lesion set with a total of 8 minutes of ablation time. In some patients, usually with tricuspid regurgitation, 3 right atrial ablations are placed within 6 minutes of ablation time. The procedure added 10.5 minutes and 13.4 minutes of cross clamp and bypass times. For patients with 3-minute box lesion freezes, 12-month freedom from atrial fibrillation off anti-arrthymics was 90%. There was no increase in peri-operative complications and late survival was the same as mitral patients without AF and a matched population.

“Swiss-cheese” multiple muscular ventricular septal defects (VSDs) are often very challenging to close. Herein we describe our trans-ventricular approach that allows simple and effective closure of multiple muscular VSDs and does not appear to adversely affect ventricular function. (Video 1 and 2)

Diaphragm dysfunction, either from congenital eventration or acquired paralysis, impairs the ability of the diaphragm to contract, thereby disrupting normal respiratory mechanics. While a proportion of patients will present with respiratory insufficiency or symptoms of dyspnea, the majority of patients are asymptomatic and most cases are identified incidentally on chest imaging by the presence of an elevated hemidiaphragm. In symptomatic patients, surgical plication of the diaphragm remains the gold standard treatment. Traditionally, diaphragm plication is performed through an open transthoracic approach via a posterolateral thoracotomy. However, more recently there has been increased utilization of minimally invasive techniques, including video-assisted thoracoscopic and laparoscopic approaches. Here, we present our technique for robotic-assisted transthoracic plication, with advantages including enhanced ergonomics, seamless motion, decreased surgeon fatigue, tremor filtering, and 3-dimensional vision. This approach has been demonstrated to be a technically feasible and safe option for performing diaphragm plications with an associated decreased hospital length of stay and trend towards decreased 30-day postoperative complications compared to open plication.

Transatrial re-endocardialization (TAR) is a technique used to complement conventional patch repair of multiple ventricular septal defects (mVSD). To inform operative strategy, pre-operative imaging is supplemented by pre-cardiopulmonary bypass (CPB) intraoperative epicardial echocardiography to understand the size and location of all VSDs. After standard cannulation and arrest, L-shaped right atriotomy is performed and the superior margin of VSDs are marked. Perimembraneous and moderate-large VSDs with insufficient surrounding trabeculae are closed with patch repair. Remaining small muscular VSDs are addressed by TAR, whereby the defect is closed in 2-layers with fine polypropylene suture for superficial re-approximation of adjacent right ventricular trabeculation. Success of repair is evaluated with high-pressure left ventricular injection and pulmonary-systemic flow ratio after CPB is weaned. Adding TAR to the armamentarium of mVSD repair strategies allows for reduction of patch size, thereby decreasing the risk of ventricular septal dyskinesis and heart block.

The closure of multiple muscular ventricular septal defects poses a unique challenge to the surgeon with inherent risks of residual defects, conduction blocks, and ventricular dysfunction. The trabeculations in the right ventricle often make it difficult to identify and visualize the edges of the defects. More recently 3 dimensional (3D) models are increasingly being used in the management of various complex congenital heart defects. We present our technique of closing multiple muscular ventricular septal defects (VSDs) using individualized 3D printed models. The stepwise process requires a multidisciplinary approach between the cardiologist, cardiac surgeon, cardiac radiologist, and 3D engineer. As the 3D model exactly replicates the intracardiac anatomy including that of the trabeculations in the region of the multiple VSDs, this technique facilitates the precise location of the defects and obviates the requirement to ‘search’ for the defects intraoperatively. The defects can be located through a shorter right ventricular incision and the defects can be closed with a shorter myocardial ischemia time. Three-dimensional printing facilitates individualization of surgical management, and we recommend the addition of 3D printing to the armamentarium of surgeons dealing with the challenge of closing multiple muscular VSDs in children.

The autoregulated, pulsatile Aeson total artificial heart (Carmat SA, Vélizy, France) is a single-unit biventricular device. The central body comprises the 2 blood pumping ventricles and separate technical compartments which house 2 electrohydraulic pumps and control electronics which employ an algorithm informed by pressure sensors and volume detection transducers in each ventricle. The prosthesis is connected by an 8 mm driveline, which exits the skin in the lower right quadrant, to an external routing module and a controller powered by batteries. Since the first implantation took place in 2013, more than 50 patients have been successfully implanted during clinical studies, and commercially after the Aeson obtained its CE mark in 2020, as a bridge to transplant device. The size of the device and the lack of adhesions around the device body have been shown to facilitate relatively easy explanation and subsequent transplantation.

With the growing experience, the implant procedure has evolved from experimental to a well-established routine procedure. The purpose of this article is to provide a guide for potential implanters in order to ensure that the advanced design benefits of the Aeson TAH are realized by incorporating optimal surgical techniques.

Anatomic segmentectomy becomes an actual therapeutic option for the thoracic surgeon on lung cancer treatment. Mostly applied for early-stage lung cancer resections, its applications go further passing from localized benign disease and metastatic lung lesions. Due to the anatomic complexity and the vascular anatomic variations of the segments, It is usually more technically challenging than a standard lobectomy. This complexity is noted mainly in single-segment resections where there is a need to treat more than 1 intersegmental plane. The great anatomical variation and the high occurrence of lesions in the upper lobes make it important to study sublobar resections of the right upper lobe. Performing it with minimally invasive access requires a great knowledge of the technique to standardize the approach avoid pitfalls and optimize the procedure outcomes. This paper aims to describe the anatomic segmental resections of the right upper lobe performed by minimally invasive access, anticipating instructions for video thoracoscopic and robotic approaches.