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

The Ross procedure continues to be the best procedure to address unrepairable aortic valve pathology, especially in young adults. The Achilles heel of this procedure has been aortic root dilation and the potential need for a reoperation that may be associated with slightly increased risks in addition to the need for intervention on the pulmonary outflow tract. Modifying the Ross procedure by autograft inclusion inside a Dacron graft seems to have the potential advantage of stabilizing the autograft diameter, which may be associated with improved durability and decrease the need for future intervention. Although the long-term data are satisfactory, the pulmonary homografts are costly and have limited availability, so the need for alternate options for reconstruction of the right ventricular outflow tract exists. Utilization of the autologous pericardium in the reconstruction of neo-pulmonary leaflets may be considered an alternative to other pulmonary valve reconstruction options. We present a few different modifications to the Ross procedure that may have the potential of being more reproducible and more cost effective, especially in areas of the world where homografts and bioprosthetic valves are not readily available.

Several techniques for the surgical correction of congenital supravalvular aortic stenosis have been devised. We describe the step-by-step surgical approach of a slide aortoplasty to correct localized supravalvular aortic stenosis in a 3-year-old child with Williams syndrome.

Patients with secundum atrial septal defects preferentially undergo device closure;  however, this procedure is not always feasible. Instead, patients can safely undergo surgical closure. At a time when minimally invasive surgery can now be utilized with improved cosmetic results and the same excellent outcomes as a conventional sternotomy for an atrial septal defect closure, we propose the partial lower ministernotomy as the new standard for surgical atrial septal defect closure. We present a surgical case demonstrating this technique.

In patients with suspected interstitial lung disease, diagnostic confirmation can be achieved through an awake video-assisted surgical lung biopsy. This procedure enables the collection of a substantial amount of parenchymal tissue for diagnostic purposes while minimizing perioperative complications associated with mechanical ventilation with the patient under general anaesthesia, given the impaired lung function due to the underlying condition.

An 8-week-old, 3.4-kg infant, who was diagnosed prenatally with tetralogy of Fallot and absent pulmonary valve syndrome, was intubated after birth and failed extubation due to severe tracheobronchomalacia. He was deemed inoperable prior to being transferred to our institution. The left pulmonary artery was severely aneurysmal to the point of occupying almost the entire left upper lobe. Standard tetralogy of Fallot repair was performed together with bilateral reduction pulmonary arterioplasties and a modified Lecompte manoeuvre. No interventions were done directly to the airways. In this video tutorial, we demonstrate the technique used and the outcomes.

This procedure is carried out via a full sternotomy using standard aortic and bicaval cannulations. For the aortic and pulmonary anastomoses, selective antegrade unilateral cerebral perfusion is used after cooling the body temperature to 26 °Celsius. A 12-mm Hancock conduit is interposed between the pulmonary artery and the proximal descending aorta using standard running suture techniques. Critical decisions during the challenging postoperative management include, but are not limited to, the use of venovenous extracorporeal membrane oxygenation for intermittent support in case of systemic deoxygenation and the anticoagulation and antiplatelet regimen to provide optimal long-term function of the intermittently opening Hancock valve.

With the increase of patients with adult congenital heart disease, the number of high-risk multiple redo sternotomies is increasing. Calcified conduit embedded in the sternum or large vessels attached to the sternum presents an especially challenging case. This video tutorial presents a simple safe redo sternotomy technique using an ultrasonic bone scalpel in such high-risk patients. The ultrasonic bone scalpel has a narrow cutting blade that oscillates longitudinally. Because the movements of the blade have a much smaller amplitude and faster speed than those of the usual saw, making a precise cut is possible when holding the ultrasonic bone scalpel onto the bone, and soft tissue can be dissected out with a quick touch. A narrow blade can shave the sternum on the conduit when the layer between the sternum is identified. A lack of understanding of the character of the ultrasonic bone scalpel often limits its potential. This video tutorial demonstrates the key techniques of the fine manipulation of the blade: "hold-quick touch-shave" for the effective and safe use of an ultrasonic bone scalpel.

Venoarterial extracorporeal membrane oxygenation weaning strategies are not standardized. When dealing with patients with complex physiologies and borderline haemodynamics, it is prudent to have a fail-safe method of approaching decannulation from extracorporeal membrane oxygenation. Standardizing the extracorporeal membrane oxygenation weaning strategy with a pump-controlled retrograde trial off protocol seems a feasible alternative to traditional venoarterial extracorporeal membrane oxygenation weaning approaches. We advocate that having a pump-controlled retrograde trial off protocol for weaning could be done consistently, reliably and validly to assess a patient's ability to be weaned off extracorporeal membrane oxygenation successfully. The advantages of a pump-controlled retrograde trial off versus traditional weaning strategies are threefold: (i) It allows one to do a stress test on the cardiorespiratory reserve of the patient with borderline haemodynamics while having the extracorporeal membrane oxygenation circuit as a fail-safe protection. (ii) It can be standardized and consistently performed regardless of the operator. (3) It allows multiple attempts at weaning without sacrificing the extracorporeal membrane oxygenation circuit by a reduction in risk of circuit clotting. We present the step-by-step approach for conducting a pump-controlled retrograde trial off protocol with video in a neonate with myocarditis, with improving but borderline myocardial function and moderate to severe mitral regurgitation. The pump-controlled retrograde trial off was able to predict successful separation from extracorporeal membrane oxygenation, and the patient was subsequently decannulated successfully.

Prostaglandin E1 is a potent vasodilator that prevents the ductus arteriosus from closing. Its use in neonates with cyanotic heart defects has revolutionized the management of children with cyanotic heart defects. Although the use of prostaglandin E1 is a temporary solution, the establishment of dependable pulmonary blood flow is of paramount importance. Several strategies with limitations are available (patent ductus arteriosus stenting, a central shunt, a Blalock-Thomas-Taussig shunt). We present a neonate with tricuspid atresia and tortoises restrictive patent ductus arteriosus on a high dose of prostaglandin E1 who underwent a Laks-type central shunt for branch pulmonary rehabilitation.

The plane running between two adjacent pulmonary segments consists of a very thin layer of connective tissue through which the pulmonary vein also runs. To perform an anatomically correct segmentectomy, this segmental plane needs to be divided. Before the operation, the locations of vessels and bronchi are confirmed by three-dimensional computed tomography. A 4-cm minithoracotomy skin incision is made in the fourth intercostal space on the antero-axillary line, and two ports are added for the scope and the assistant surgeon. Dissection is performed bluntly with confirmation of the pulmonary vein. If the segment is divided along the anatomically correct segmental plane, the pulmonary parenchyma in the residual segments is not compressed by the stapler and inflates fully without deformity. The divided intersegmental planes fit together completely, thereby closing small air leaks. The goal of a segmentectomy is to preserve the pulmonary parenchyma to retain its function. However, resection of a central segment such as the ventral segment (S3) of the left upper lobe by the stapler leaves small shrunken segments and markedly reduces the volume of the residual lung. An anatomically correct segmentectomy by blunt dissection can be performed with correct division of the segmental plane, and no fibrin glue or biomaterial sheets may be necessary.Introduction The goal of a segmentectomy is to preserve the pulmonary parenchyma to maintain its function. However, resection of a central segment such as S3 of the left upper lobe by a stapler leaves small shrunken segments and markedly reduces the volume of the residual lung. To perform an anatomically correct segmentectomy, the segmental plane needs to be divided by blunt dissection with confirmation of the pulmonary vein. If the segment is divided along the anatomically correct segmental plane, the pulmonary parenchyma in the residual segments will not be compressed and will fully inflate without deformity. Air leakage from the segmental plane can be corrected with absorbable thread sutures, and any small air leaks are closed due to the close fitting of the divided intersegmental planes.