Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

Per oral endoscopic myotomy is an endoscopic procedure that accesses the potential third space of the esophageal wall—the submucosa—to perform a myotomy of the distal esophagus and gastroesophageal junction. This article describes the series of steps along with tips and suggested solutions to performing a POEM in patients with achalasia.

Durable mechanical circulatory support options for patients with biventricular failure are limited. One emerging strategy is the use of 2 fully magnetically levitated durable ventricular assist devices (HeartMate 3s) in a biventricular configuration. The use of a HeartMate 3 as a right ventricular assist device (RVAD) requires several complex technical modifications. Here, we provide step-wise detailed figures and a comprehensive description of bilateral HeartMate 3 insertion, with a particular focus on right atrial inflow cannulation for the RVAD. Potential pitfalls and solutions are also described.

Ebstein anomaly (EA) is a congenital heart disease, which main feature is the rotational displacement of the tricuspid valve (TV) into the right ventricle (RV). Tricuspid regurgitation and RV dysfunction are common findings. The Cone procedure is a well-recognized technique for anatomical repair of EA. The basic principles of Cone repair are mobilization of all available TV leaflets and construction of a cone-like valve that is reattached to the normal atrioventricular junction. Since creation of the technique in 1993, we have introduced many technical refinements to improve TV performance, prevent cardiac arrhythmias, and improve RV function. Here, we provide some surgical details to avoid atrioventricular block and coronary compromise, facilitate patient recovery, and provide sustainable long-term results. From 2016, we have applied these refinements to 110 consecutive patients at our institution, including those with previous Starnes procedure or valve replacement, resulting in no mortality, very low morbidity, and excellent valve function.

Surgical management of critically ill neonates with Ebstein anomaly (EA) remains challenging with most published hospital and 1-year mortalities approximating 30%-40% irrespective of the surgical or palliative strategy. We have adopted an initial bi-ventricular repair strategy for most symptomatic neonates and young infants since 1994 and sought to identify whether our simplified tricuspid valve repair will be associated with improved outcome by a wider audience of experienced surgeons. The essential principles of the repair include (i) monocusp tricuspid valve repair based on the anterior leaflet, (ii) fenestrated ASD closure), (iii) repair of all associated cardiac defects, and (iv) reduction right atrioplasty. The technique of tricuspid valve repair depicted in the following figures was associated with a 100% 1-year survival for the most recent 6 years (n = 9).

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.