Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

The current conventional open TAAA repairs are performed by select centers around the world with good outcomes. However, lesser experienced centers often encounter difficulties in replicating similar results of open TAAA surgeries. The modified branch-first open repair of TAAA has shown to be effective in minimizing visceral and renal complications by providing continuous visceral blood flow throughout the procedure. By debranching the visceral vessels first, we can perform this complex aortic procedure in a more controlled manner as compared to the traditional clamp and sew technique which requires speed, precision and experience. The entire repair can be performed on beating heart by deriving native blood flow via a closed circuit or a modification of the left heart bypass and continuously perfusing the abdominal viscera, thus avoiding cardiopulmonary bypass or deep hypothermic circulatory arrest which helps minimize bleeding and overall morbidity associated with extensive TAA surgeries. Adequate pre-operative planning is imperative to prevent spinal cord complications and intra-operative emergencies.

The Ross procedure is superior as a valve substitute in children and early adulthood because of its clear survival benefits. The free standing-root implantation is associated with failure of the autograft and inclusion techniques that support externally the autograft warrants its longevity. The current technique consists in the implantation of the autograft within the native aortic root thereby both supporting the autograft and avoiding any coronary distortion.

Autograft stabilization has proven beneficial in adults but the same technique could not always be adopted in growing children undergoing the Ross procedure. The major concern regarding the longevity of autograft after the Ross operation in a growing child is the lack of means to stabilize the aortic root. Herein we described a modified root inclusion technique that achieves aortic root stabilization using autologous tissue.

Though their etiology and pathology are distinct, the treatment of symptomatic diaphragm eventration and paralysis is the same – diaphragm plication. Though there is little data to objectively compare plication techniques, all offer significant improvement in symptoms, pulmonary function, and respiratory quality-of-life scores. Nonetheless, potential advantages of a robot assisted laparoscopic approach to plication include lower morbidity than thoracotomy and laparotomy techniques; avoidance of single lung ventilation, less intercostal nerve pain, and greater working domain compared with thoracotomy and thoracoscopic approaches; and enhanced dexterity as compared with standard laparoscopic instrumentation.

Aberrant subclavian arteries are a result of unusual involution of the branchial arches resulting in persistent arteries that can cause tracheal or esophageal compression. Many are incidental findings but may be associated with dysphagia (dysphagia lusus naturae, Latin for “jest of nature”), a long history of asthma treatment for wheezing, or more uncommonly, aneurysms or aortic dissection. There are 5 basic approaches for repair discussed herein, determined by which subclavian artery is involved and where the aortic arch and descending thoracic aorta lie, as well as the size of the latter, classified as Groups A to E, in order of frequency. These include: A: Aberrant RSCA and left arch; B: Aberrant LSCA and right arch; C: Aberrant RSCA, no significant Kommerell's and descending aneurysm; D: Aberrant LSCA and right-sided arch but compression from a vascular ring; and E: Aberrant RSCA and extensive arch and descending aneurysm.

Postinfarction ventricular septal rupture, or postinfarction ventricular septal defect is rare but lethal if not repaired, and various repair techniques have been tried over many years. However, there still remain problems of high mortality rates and shunt recurrence, particularly in the acute phase and posterior defects. The extended sandwich patch repair via the right ventriculotomy was developed to overcome those problems. The 3 key features are, first, access and eventual closure through the low-pressure right ventricle; second, using the septal defect for a portal to reach into the left ventricle; and third, “sandwiching” the defect between 2 patches, both large enough to be anchored by transmural sutures through relatively stable myocardium. Detailed technical steps are presented here.