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

We present an enhanced percutaneous decannulation technique for a patient undergoing veno-arterial extracorporeal membrane oxygenation. This innovative approach uses two distinct percutaneous vascular devices, offering a more reliable and more effective method for decannulation.

Surgical isolation of left atrial posterior wall (box lesion) with left atrial appendage closure are good options for treating patients with atrial fibrillation concomitant with another cardiac surgical procedure in case we prefer not to open the left atrium. We describe a full box ablation, left atrial appendage closure and aortic valve replacement through a J-shaped ministernotomy through the fourth intercostal space. The box lesion ablation is performed using the Isolator Synergy and Bipolar RF Ablation Clamp with the jaws placed in the oblique and transverse sinuses from the right side. The left appendage is excluded and electrically isolated with the AtriClip Flex-V; the aortic valve is replaced by a sutureless Perceval bioprosthesis. This technique allows us to perform a complete box lesion and left atrial appendage  closure easily for patients with paroxysmal or persistent atrial fibrillation in which we do not open the left atrium, such as those with aortic valve surgery and/or coronary artery bypass grafting.

Tracheobronchomalacia is a condition of dynamic airway collapse due to weakness of the tracheobronchial wall. When conservative management, including continuous positive airway pressure, fails to control symptoms or improve quality of life, surgical intervention may be warranted. In this case report, we present a surgical technique of tracheobronchoplasty via the right posterolateral thoracotomy in a patient with severe tracheobronchomalacia.

Bronchogenic cysts are rare congenital foregut anomalies, often detected incidentally. We report the case of a 24-year-old female who was incidentally detected during a routine health check-up to have a mediastinal mass. Preoperative chest computed tomography imaging suggested a benign bronchogenic cyst. Minimally invasive video-assisted thoracoscopic surgery was planned for its excision. Intraoperatively, a pericardial defect and a feeding artery arising from the aortic arch were noted. The patient recovered uneventfully and was discharged on postoperative day 3. This case demonstrates the utility of video-assisted thoracoscopic surgery in the excision of bronchogenic cysts, in the presence of these intraoperative findings with the advantages of less surgical trauma and faster recovery.

Left ventricular pseudoaneurysms are rare but serious mechanical complications of acute myocardial infarction. These defects are most often approached surgically, though there are insufficient data supporting certain surgical techniques over others. In this video tutorial, we demonstrate the surgical repair of a large left ventricular pseudoaneurysm in a patient who presented two weeks after an acute myocardial infarction. The patient underwent a transatrial endoventricular patch repair with mitral valve replacement and was weaned off cardiopulmonary bypass without the need for additional mechanical circulatory support. She recovered uneventfully and was discharged home.

Robotic-assisted, minimally invasive direct coronary artery bypass is a surgical technique that involves robotic-assisted harvest of the left internal mammary artery, small left-anterior thoracotomy and minimally invasive, off-pump, direct left internal mammary artery to left anterior descending artery anastomosis. It is indicated in the setting of proximal or diffuse single-vessel left anterior descending artery disease, chronic total occlusion of the left anterior descending artery or a hybrid approach to revascularization in combination with percutaneous treatment of other lesions. Benefits include avoidance of sternotomy and rapid recovery, particularly in medically complex patients, while achieving the survival benefit associated with a left internal mammary artery-left anterior descending artery anastomosis. Although there is an initial learning curve for surgeons, an understanding of positioning and exposure techniques can minimize early challenges. We present a step-by-step video tutorial of robotic-assisted, minimally invasive direct coronary artery bypass, including patient positioning, robotic port orientation, analgesic and local anaesthetic strategies, conduit harvest and anastomotic technique.

Postintubation subglottic tracheal stenosis remains a prevalent complication in patients who require prolonged periods of intubation, with an incidence of up to 11%. Transcervical tracheal resection and reconstruction remain the gold standards for definitive treatment of stenotic regions that fail trials of non-surgical interventions, including local steroid injections, cryotherapy and balloon dilation. Despite its high success rate, it is one of the more technically difficult procedures in thoracic surgery. In this case report, we document our approach to a patient with severe symptomatic tracheal stenosis operatively managed with meticulous dissection utilizing a low collar incision, transcervical tracheal resection and a primary anastomosis.

The patient presents with a genetic condition named Li-Fraumeni syndrome, which predisposes her to multiple neoplasms during her lifespan. Due to the chemotherapeutic treatment of an osteosarcoma, the patient presents with cardiotoxicity secondary to doxorubicin that is refractory to conventional management. The patient is initially stabilized with a peripheral veno-arterial extracorporeal membrane oxygenation device, with no improvement after 14 days of support. Later she was assisted with a HeartMate 3 mechanical circulatory device as a bridge to candidacy or as a destination therapy. She is the first paediatric patient in Spain to be assisted with long-term circulatory support using the HeartMate 3 device.

Pancoast tumours, a rare subset of superior sulcus tumours, arise at the apex of the lung and pose significant surgical challenges due to their anatomical location and propensity to invade adjacent critical structures, including the brachial plexus, subclavian vessels and the thoracic spine. Historically, these tumours were considered inoperable, but advancements in multimodal treatment, including neoadjuvant chemoradiotherapy followed by surgical resection, have improved survival rates. Conventional open surgical techniques are associated with significant morbidity, prolonged recovery and suboptimal visualization of critical structures. Robotic-assisted thoracic surgery, particularly with the da Vinci Xi surgical system, offers enhanced three-dimensional visualization, dexterity and precision in confined spaces, potentially transforming the surgical management of these complex resections. This video tutorial explores the application of a robotic-assisted Pancoast tumour resection using the da Vinci Xi platform, focusing on perioperative management and patient outcomes.

Periareolar incision for endoscopic aortic valve replacement via the 9-suture technique Femoral Vessel Exposure Incision above the groin crease reduces complications. Partial vessel exposure (no full isolation) with purse-string sutures (4/0 Prolene for vein, pledgeted 5/0 Gore-Tex for artery). Surgical Access Periareolar incision (third intercostal space): muscle-sparing, hidden scar, Alexis retractor for exposure. Left ventricular vent (fifth intercostal space): CO₂ insufflation (2 L/min) to prevent air embolism. Camera port (third intercostal space: for visualization and retraction). Femoral Cannulation Seldinger's technique under transoesophageal echocardiography guidance; venous cannula to the superior vena cava (vacuum-assisted), artery. Pericardiotomy and Clamp Placement Incision anterior to phrenic nerve; stay sutures for exposure. Chitwood clamp inserted via second intercostal space to stabilize the aorta. Cardioplegia and Aortotomy Antegrade Custodiol cardioplegia via 3-0 Prolene purse-string suture. Horizontal aortotomy after cross-clamping. Valve Excision and Suture Placement (9-Suture Technique) Valve excised; annulus decalcified. Pledgeted horizontal mattress sutures (3 commissural, 2 per cusp) placed strategically. Valve Implant and Closure Sutures passed through the prosthetic valve, parachuted, secured with Cor-Knot. Aortotomy closed in two layers (pledgeted mattress + running suture). De-airing and Weaning Trendelenburg, left ventricle vent suction, isolated lung ventilation. Pacing wires placed; pericardium closed. Chest Drain and Closure Drains inserted; femoral cannulae removed post-heparin reversal. Periareolar incision closed with muscle suture for cosmesis. Outcome No paravalvular leak, early extubation (2 h), discharge by postoperative day 4. Cosmetic advantage, less pain, faster recovery versus sternotomy. Reduced suture count lowers left ventricular outflow tract gradients without increasing leak risk. Conclusion This minimally invasive approach improves outcomes and patient satisfaction, supported by optimized anticoagulation (international normalized ratio 1.5-2.0) for newer version of mechanical valves.