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

Gradual dilatation of the neo-aortic/pulmonary root or development of an autograft aneurysm and associated valve regurgitation is a major fear and a serious late complication after the Ross procedure to preserve the "principle of a living valve" after the Ross operation by performing the valve-sparing reimplantation technique (David procedure). This article addresses the main peculiarities of this redo scenario compared to a primary/standard David procedure.

A male neonate (2.5 kg) who presented with an interrupted aortic arch type C, hypoplasia of the aortic valve and left ventricular outflow tract obstruction received bilateral pulmonary artery bands as a first step of a hybrid interim palliation. Due to an intimal tissue flap at the origin of the left common carotid artery and a high-risk situation for PDA stenting, a complete early correction was undertaken. For full correction, the large curvature of the aortic arch was reconstructed using the aberrant right subclavian artery as a free graft by implanting it between the right and left common carotid arteries. The left common carotid artery was shortened, and an intimal tissue flap at the origin of the vessel was removed. A Damus-Kaye-Stansel anastomosis was created, and the ventricular septal defect was closed through a right ventricular incision. Right ventricular-to-pulmonary artery continuity was established with a Contegra bovine jugular vein conduit.

A combined en bloc heart and liver transplant is a rare form of a combined dual organ transplant in which the donor heart and liver remain connected via the inferior caval vein both during procurement and during the transplant. We present a patient who underwent a combined en bloc heart and liver transplant due to heart failure and cirrhosis, after having previously undergone repair of complex biventricular congenital heart disease.

This patient was a septuagenarian female with a past medical history of hypertrophic cardiomyopathy with systolic anterior motion and moderate mitral regurgitation. Preprocedural transoesophageal echocardiography did not show any abnormal papillary muscle. An elective alcohol septal ablation was performed. During alcohol septal ablation at the catheterization laboratory, the patient developed acute cardiogenic shock with pulmonary oedema that required intubation. Transoesophageal echocardiography showed worsening obstruction of the left ventricular outflow tract due to swelling of the septum with severe mitral regurgitation. Emergency surgery via a median sternotomy revealed anomalous papillary muscles with direct insertion into the body of the leaflet and attachment to the free edge of the anterior leaflet (Mayo classification type II). The anterior leaflet and abnormal papillary muscles were resected, followed by septal myectomy through the same exposure. The mitral valve was replaced with a 29-mm tissue valve. Postoperative transoesophageal echocardiography confirmed the release of the left ventricular outflow tract obstruction. The patient's postoperative course was uneventful. This case highlights a rare but serious complication after alcohol septal ablation. Whereas anomalous papillary muscle is one of the important mechanisms of left ventricular outflow tract obstruction, its diagnosis can be challenging in a subset of patients prior to surgical repair.

The Commando procedure is an important tool to address extensive calcification of the aortic and mitral valves associated with radiation heart disease. We present a symptomatic patient with radiation heart disease associated with calcification of the mitral and aortic valves and the aortomitral curtain, which is typical of this pathology. The surgical approach consisted of exposure through aortotomy and left atrial dome, followed by aortic and mitral valve debridement, aortic and mitral valve replacement, with aortomitral curtain reconstruction using bovine pericardial patch. This procedure avoids the challenges associated with double valve repair and allows replacement with larger valves.

A discussion of an internal mammary artery aneurysm is a rare finding in the literature. This condition can cause serious complications, including haemothorax and pneumo-haemothorax, and can lead to haemorrhagic shock; it can also be fatal. These effects can be explained by the rate of flow of the blood in the internal mammary artery, that is, 150 ml/minute, which leads to a blood loss of one litre in minutes. As reported in the literature, it has many different clinical presentations. Because an internal mammary artery aneurysm occurs so rarely, agreement regarding the best way to manage its treatment is rare. It can be discovered accidentally in imaging scans. The patient can present with chest pain, dyspnoea, or a mass in the chest wall, especially near the breast in women. We present a new management technique that, to the best of our knowledge, has not yet been described in the literature. Video-assisted thoracoscopic surgery could be used as a safe approach for managing such cases. It provides minimally invasive access and is less traumatic than open surgery. The procedure performed on our patient was uneventful. The artery was clipped, and the aneurysm was resected successfully. The total hospital stay was two days, and no complications occurred.

The Berlin Heart EXCOR is used in paediatric patients with ventricular failure for temporary support as a bridge to a cardiac transplant or, occasionally, as a bridge to ventricular recovery. Neonates, infants and children who are supported with ventricular assist devices while gaining weight also have an increased demand for cardiac output while supported. Some patients might need a few pump exchanges to meet circulatory needs while growing. In this case report, we present the step-by-step technique for exchanging and upsizing the Berlin Heart EXCOR single ventricle-ventricular assist device in a 5-kg baby.

Ischaemic spinal cord injury remains a significant challenge in thoracoabdominal aortic repairs. Modern techniques have reduced spinal cord injury rates yet managing patients during and after thoracoabdominal aortic repairs remains complex. This article outlines our comprehensive approach to the prevention of spinal cord injuries in open thoracoabdominal aortic repair operations, focusing on the placement of cerebrospinal fluid drain and intraoperative strategies to enhance spinal cord protection. Preoperative planning involves thorough patient assessment, prehabilitation and nutritional support, detailed imaging review, thorough operative planning and patient blood management. Intraoperative measures include the use of neuromonitoring techniques like near-infrared spectroscopy and motor evoked potentials, as well as cerebrospinal fluid drainage together with blood pressure management to optimize spinal cord perfusion. Postoperative management focuses on maintaining haemodynamic stability with high mean arterial pressure, along with close monitoring and management of the cerebrospinal fluid drain to improve spinal cord perfusion. Additionally, thromboelastography-guided strategies are crucial for optimizing coagulation and addressing postoperative bleeding complications. The goal of this multifaceted approach is to minimize the risk of spinal cord injury, thereby improving patient outcomes and reducing the incidence of postoperative paraplegia. Our video tutorial shows some of our preoperative and intraoperative techniques for spinal cord protection in thoracoabdominal aortic repairs.

Pulmonary sequestrations comprise a spectrum of congenital lung malformations, with abnormal lung tissue lacking connection with the tracheobronchial tree, supplied by an aberrant systemic artery. Until a few years ago, lobectomy was considered the standard treatment for intralobar pulmonary sequestration. However, minimally invasive sublobar resection gained a place as an interesting alternative therapeutic approach, guided by indocyanine green and computed tomography-based 3-dimensional anatomical models. Like pulmonary sequestrations,  pulmonary pseudosequestrations are a congenital lung malformation, but characterized by a normal lung tissue fed by systemic arterial branches. To the best of our knowledge, there are no published cases of pulmonary pseudosequestration combined with sequestration. We present a case of an intralobar pulmonary sequestration coupled with an adjacent pseudosequestration, resected using thoracoscopic surgery with the aid of a 3-dimensional anatomical model and indocyanine green.

Robotic-assisted thoracic surgery has emerged as a prominent technique for performing radical thymectomies in patients affected by early-stage thymic tumours. This technique is favoured because of its high ergonomics, superior image quality, enhanced instrument manoeuvrability and exceptional precision. Among the different surgical approaches developed, the unilateral and the bilateral intercostal approaches are the most widely diffused. The subxiphoid approach offers several advantages over these approaches, providing a wide visualization of the entire mediastinum and of both pleural cavities while enabling bilateral dissection through a single bilateral small intercostal incision. It brings an optimal central view of the mediastinum, easy control of both phrenic nerves and enhanced dissection at the level of the superior thymic horns and the left brachiocephalic vein, all while minimizing intercostal trauma. We present a robotic subxiphoid radical thymectomy using the da Vinci Xi platform, illustrated by a case involving a patient with a 5-cm thymoma close to the left phrenic nerve.