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

Findings in the present case underscore the potential of sutureless aortic valve utilization in patients with prior prosthetic root replacement, thereby obviating the need for high-risk procedures such as replacing a prosthetic root or reimplanting a coronary artery. A 75-year-old male who had undergone a Bio-Bentall operation with a bioprosthetic Trifecta valve for aortic regurgitation and annuloaortic ectasia eight years prior presented with symptoms of heart failure, notably dyspnoea, attributed to prosthetic valve dysfunction. Although a transcatheter aortic valve implant is often recommended, it was deemed unsuitable in this case due to a history of type B aortic dissection. Aortic valve replacement utilizing a sutureless Perceval valve with a Trifecta cuff as the valve ring was successfully performed through a repeat median sternotomy, which enabled aortic valve replacement via a higher than usual aortotomy with minimal adhesion dissection. Despite the inherent risks associated with a reoperation post-Bentall surgery, the duration of the procedure was notably short, with only 85 minutes required for cardiopulmonary bypass and 51 minutes for aortic clamping, resulting in an overall operating time of 198 minutes, thus highlighting the minimally invasive and safe nature of this approach.

It is generally accepted that the definitive treatment for irreparable aortic root disease is aortic root replacement with a valved conduit - the Bentall procedure. However, we try to follow a reparative strategy for all aortic root pathology whenever possible. Our "root-sparing" philosophy is achieved by restoration of physiological aortic root dimensions by the Florida sleeve technique and aortic cusp substitution by neocuspidization. The combination of both strategies allows for full reconstruction of the root, instead of its replacement. Our modification is called FLOZ, from "FLorida + OZaki".

We present the case of a failed papillary muscle approximation successfully treated using a totally endoscopic, robotic-assisted approach.

The patient had a unicuspid aortic valve with severe aortic stenosis and a mildly dilated and hypertrophied left ventricle with moderately impaired systolic function. Herein we demonstrate the technique of severely dysplastic unicuspid aortic valve repair in the neonatal period.

A 76-year-old patient with non-ST elevation myocardial infarction was admitted to our hospital. Coronary angiography revealed significant left main and two-vessel coronary artery disease. Preoperative testing indicated severe left ventricular dysfunction. The patient was scheduled for urgent off-pump coronary artery bypass grafting. Due to the low ejection fraction, an intra-aortic balloon pump was inserted in the operating theatre before sternotomy, to enhance the patient's haemodynamic stability during surgery. A 6 Fr introducer was inserted into the femoral artery under echocardiographic guidance. Using a 150-cm guidewire, the intra-aortic balloon catheter was advanced through the introducer to the descending thoracic aorta. The catheter's tip position, just distal to the origin of the left subclavian artery, was confirmed via transoesophageal echocardiography. The external part of the catheter was secured to the skin and connected to the balloon console. Therapy was initiated, and the inflation/deflation parameters were optimized. A double off-pump coronary artery bypass was performed via median sternotomy. The patient remained haemodynamically stable throughout the surgery, aided by the intra-aortic balloon pump, and careful volume and vasoactive management. The patient was extubated promptly, and the device was removed on the second postoperative day without complications.

A 70-year-old female patient was referred from a peripheral hospital to our department with an incidental finding of an intra-aortic mass. Chest access was gained by a median sternotomy, and visualization of the intra-aortic mass was achieved using epiaortic ultrasound. After systemic heparinization, arterial cannulation was performed in the distal aortic arch. The right atrium was cannulated; the patient was cooled to a target temperature of 22°C. With the patient under hypothermic circulatory arrest, a transverse aortotomy was performed 3 cm proximal to the brachiocephalic trunk, and prompt removal of the tumour was achieved. After establishing antegrade cerebral perfusion, proper visualization of the aortic wall was achieved, and no pathological alterations of the aortic wall were encountered. After closure of the aorta and complete rewarming, the patient was easily weaned from cardiopulmonary bypass. Chest closure was performed in the usual fashion. The postoperative course was uneventful, and the histopathological diagnosis was thrombus formation. Consequently, the patient was placed on lifelong phenprocoumon therapy.

Bicuspidization is a valid option for unicuspid aortic valve repair, in which creating symmetrical commissural orientation is essential for improved outcomes. However, the right coronary orifice often interferes with symmetrical attachment of the neocommissure. In a paediatric patient without aortic root dilation, we rotated the right coronary orifice clockwise by cutting out a triangular piece of the non-coronary sinus wall and augmenting it between the left and right coronary sinuses. A neocommissure with patching was sewn to the left side of the right coronary orifice, and the symmetrical bicuspidized configuration was adjusted in a standardized fashion according to the cusp effective height measurement.

Despite the prognostic benefits for patients, surgical resection following nivolumab combined with platinum-based chemotherapy is technically challenging due to the inflammation or fibrosis in the thoracic cavity, particularly around the hilar structures. Performing this complex surgical resection using a minimally invasive approach requires the advantages offered by robotic surgery, including a high-definition 3-dimensional surgical view, precise, tremor-free motion and articulated forceps, which facilitate safe resection following neoadjuvant immunochemotherapy. In this video tutorial, we demonstrate a robotic right lower lobectomy performed after neoadjuvant nivolumab combined with platinum-based chemotherapy, highlighting the specific techniques and nuances involved. The console time was 138 minutes, with minimal blood loss. The patient's postoperative course was uneventful; the chest tube was removed on postoperative day (POD) 1, and the patient was discharged on POD 2. The final pathological report revealed pTisN0M0, stage 0, squamous cell carcinoma.

We present a case report detailing the surgical intervention in a patient with prosthetic aortic valve endocarditis complicated by a paravalvular abscess extending to the mitral-aortic fibrosa. Urgent surgery was required due to severe detachment of the prosthetic aortic valve, marking her third cardiac surgical procedure. Notably, preoperative imaging revealed the presence of a persistent left superior vena cava, a rare vascular anomaly requiring specialized cannulation techniques. The surgical approach involved removal of the infected tissue and prosthetic valve, followed by replacement with a cryopreserved aortic homograft, chosen for its anatomical adaptability.

Carinal reconstruction remains a technically challenging procedure for thoracic surgeons due to the complexity of airway resection and management. This is typically performed in the setting of tumour resection affecting the carina and distal trachea. Airway management of patients undergoing surgical resection of tumours involving the carina is highly challenging. This is due to an open, shared airway and the need for single-lung ventilation to facilitate surgery. Common modalities used for intraoperative ventilation include cross-table ventilation, veno-venous extra-corporeal membrane oxygenation and cardiopulmonary bypass. Cardiopulmonary bypass is usually avoided due to the requirement of full heparinization, which increases the demands of a technically challenging procedure, in addition to its contraindication in oncological resections. Extra-corporeal membrane oxygenation is not readily available in most thoracic units. This leaves cross-table ventilation, which is commonly used for open thoracotomy and sternotomy cases, but has never been reported for minimally invasive procedures.  Specifically, to the best of our knowledge, cross-table ventilation has never been used for minimally invasive robotic carinal reconstruction. We present a step-by-step video tutorial in performing surgical resection of a mediastinal tumour that was found invading the carina. This was performed in a young patient who underwent carinal reconstruction using a novel technique combining cross-table ventilation and robotic-assisted surgery.