Multimedia manual of cardiothoracic surgery : MMCTS / European Association for Cardio-Thoracic Surgery最新文献

Precise knowledge of bronchovascular anatomy is critical for lung surgery. In this video tutorial, we present a manual, semi-automatic segmentation workflow using open-source image processing software to create detailed three-dimensional models of the lungs from computed tomography scans. Structures segmented include the bronchus, lung lobes, pulmonary arteries and veins, and tumours. In this method, we have used various segmentation techniques including thresholding, painting, logical operations and smoothing to perform anatomical labelling. By following this workflow, segmentation times range from 1.5 to 2 hours per patient, which can be affected by both computed tomography image quality and contrast enhancement. Although manual segmentation is time-consuming, it offers a cost-effective alternative to commercial three-dimensional reconstruction software, particularly for educational and research applications.

The management of infants with Ebstein's anomaly is challenging and requires complex involvement of the multidisciplinary team. Surgical repair technique is dependent on the degree of tricuspid leaflet dysfunction and the decision to undergo univentricular or biventricular repair. Patients with a severely dysplastic tricuspid valve are less suited to a cone repair alone and require leaflet reconstruction. Currently used patch materials include autologous untreated pericardium and treated pericardium, with limitations such as unpredictable shrinkage and no growth potential, respectively. To overcome these challenges, we used living autologous wall of the right atrium to reconstruct the tricuspid valve leaflets in a 1-year-old girl with Ebstein's anomaly and a severely dysplastic tricuspid valve.

Atrial fibrillation remains a challenging condition to treat, especially in older patients with multiple comorbidities. Anticoagulation may lead to life-threatening bleeding and therefore might not be possible in high-risk patients. We report the case of a successful robotic-assisted left atrial appendage closure in such a patient, which proved to be an effective treatment strategy and provided a rapid recovery.

Anatomical segmentectomy has been established as a valid surgical option for early-stage lung cancer. However, this procedure could be technically demanding due to the anatomical variability of segmental bronchovascular structures. Misinterpretation of segmental anatomy could result in numerous postoperative complications. The routine use of three-dimensional reconstruction and preoperative planning is recommended to overcome this problem. We present a surgical case of a successfully conducted minimally invasive segmentectomy by utilizing three-dimensional reconstruction and preoperative planning.

Our goal is to present how we handled a complex case of prosthetic aortic valve endocarditis that resulted in severe complications, including an aortic root abscess, complete heart block and coronary artery embolic occlusion leading to myocardial infarction and a left ventricular aneurysm. The patient needed multi-component surgery to treat the infection and address the ventricular issues. Our approach involved exposing the right axillary artery, performing a redo sternotomy, lysing pericardial adhesions and then establishing axillary and bicaval cannulation. Myocardial protection was achieved through both antegrade and direct retrograde cardioplegia. The previous aortic valve and ascending aorta graft were removed, the coronary buttons were created and mobilized, and the aortic root abscess was debrided. The distal aortic stump was fragile and short, necessitating hemi-arch aortic replacement under brief hypothermic circulatory arrest. The left ventricular apical aneurysm was opened, clots removed and a Dor procedure was performed using a Dacron patch. The aortic root was replaced with an aortic allograft. Three epicardial leads were placed and connected to a biventricular pacemaker for resynchronization therapy. The procedure concluded without complications, and the chest was closed.

Pulmonary aspergillosis is a fungal lung infection caused by inhalation of Aspergillus spores. While traditionally associated with immunocompromised patients, it may also develop in immunocompetent individuals. The clinical presentation is wide, varying from asymptomatic colonization to invasive disease with significant morbidity. Despite advances in antifungal therapy with agents such as voriconazole, medical treatment alone often fails to achieve complete eradication of the infection, especially in cases of aspergilloma, where a dense fungal ball forms within a pre-existing pulmonary cavity. Surgical resection remains the mainstay management of localized aspergilloma. The type of surgery and how much tissue is removed are determined by the size and location of the lesion, as well as the patient's lung function. Traditionally, these operations have been performed via thoracotomy because of the complexity of the procedure and the possibility of intra-operative bleeding. However, recent developments in minimally invasive thoracic surgery, such as video-assisted thoracoscopic surgery, combined with comprehensive multidisciplinary management, offer a safer and less morbid alternative. This case demonstrates successful integration of multidisciplinary medical management, including antifungal therapy and minimally invasive surgical resection in treating a centrally located pulmonary aspergilloma.

Lung herniation occurs when the parenchyma of the lung crosses the plane of the chest wall. This can occur due to blunt or penetrating trauma, previous thoracic surgery leading to weakening of the chest wall, congenital chest wall defects, or can occur spontaneously secondary to pulmonary disease creating increased intrathoracic pressure. In this case report, we present a redo lung herniation repair using FiberTape instead of mesh or plating.

We report a case of a large distal arch and proximal descending thoracic aortic saccular aneurysm managed successfully with type I hybrid arch repair (off-pump debranching + thoracic endovascular aortic repair). Conventional open total arch replacement involves significant peri-operative risks, especially in elderly or comorbid patients, due to the need for cardiopulmonary bypass, circulatory arrest and cerebral protection. The hybrid arch repair technique combines open debranching of supra-aortic vessels with endovascular stent grafting to exclude the aneurysmal segment. This method avoids circulatory arrest, reduces operative time and minimizes complications, while maintaining the durability of open repair. It is particularly suitable for aneurysms of the distal arch and proximal descending thoracic aorta, with an adequate ascending aortic landing zone for endograft deployment.

Caseous liquefaction is a rare variant of mitral annular calcification that can lead to cavity formation in the atrioventricular groove. We report a case of mitral valve replacement in a 76-year-old woman with a large caseous cavity, coronary artery disease, severe mitral valve stenosis and atrial fibrillation. Preoperative computed tomography showed a large caseous cavity (3 x 3.5 cm) in the posterior annulus extending into the atrioventricular groove. After unroofing and evacuation, the cavity was excluded with a pericardial patch. The lower edge of the patch was sutured to the ventricular side of the cavity; valve sutures passed through the residual posterior leaflet, the upper edge of the patch and the atrial edge of the cavity. The mitral prosthesis was then secured. The patient was weaned from cardiopulmonary bypass without complications. Intraoperative echocardiography demonstrated a well-seated mitral prosthesis with no valvular or paravalvular leaks. Postoperative imaging confirmed successful exclusion of the cavity in the atrioventricular groove. The postoperative echocardiogram revealed a mean gradient of 4 mmHg across the mitral prosthesis and no mitral regurgitation. Patch exclusion of the caseous cavity is a safe and feasible approach to support implanting a mitral prosthesis and obliterating a cavity.

The use of transcatheter aortic valve implantation (TAVI) has become the most popular technique of aortic valve intervention. Classically, TAVI is performed via femoral arterial access. However, some patients who have severe peripheral arterial disease do not have safely accessible femoral arteries. In such patients, the use of carotid access has been well described via the 'clamp-and-sew' technique. We describe a minimally invasive carotid access technique for TAVI deployment. The right common carotid is accessed by a 3 cm suprasternal incision. The carotid sheath is entered, and the surgeon obtains proximal and distal control of the carotid artery. The surgeon then makes two opposing purse strings over the anterior surface of the carotid artery. The Seldinger technique is used to obtain access to the carotid artery, followed by placement of the TAVI sheath. The valve is then deployed and echocardiographically confirmed. Upon removal of the TAVI sheath, the purse strings are tightened and sequentially tied. Haemostasis is achieved and skin is closed. This minimally invasive TAVI technique provides an option for patients with unfavourable peripheral access sites while offering the benefits of TAVI compared to open valve replacement.