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

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.

Robotic aortic valve replacement is the latest advance in the field of aortic valve intervention and is increasingly being adopted by various centres with favourable early results. It allows surgeons to implant any commercially available aortic valve prosthesis (sutureless, biological, mechanical) in a surgically conventional manner, while offering minimal surgical trauma (sternum-free, rib-free, pectoralis muscle sparing). We present a step-by-step standardized procedure of robotic aortic valve replacement with a mechanical prosthesis for a young female patient with severe symptomatic aortic valve stenosis in a unicuspid aortic valve.

This video tutorial presents a step-by-step description of percutaneous lung nodule localization performed in a hybrid operating room using indocyanine green and Lipiodol under cone-beam computed tomography guidance. Preoperative localization is indicated when the surgeon anticipates difficulty identifying a pulmonary nodule by digital palpation during video-assisted thoracoscopic surgery. The combined use of indocyanine green fluorescence and fluoroscopy allows accurate intraoperative detection and confirmation of adequate resection margins.

Blunt diaphragmatic rupture is a rare injury with a high mortality rate. The pathophysiological mechanism of diaphragmatic rupture is hypothesized as an increase in intra-abdominal pressure leading to muscular disruption and subsequent visceral herniation into the pleural cavity. Left-side ruptures are more common, as the right side is protected by the liver. Abdominal contents occupying the chest cavity can become ischaemic or could have been injured during the initial trauma and, additionally, might significantly compress the lung, leading to a variety of clinical presentations ranging from chest pain and peritonitis to increased rate of breathing or respiratory distress. In this video tutorial, we present a polytrauma patient after a motor vehicle collision, who sustained traumatic diaphragmatic rupture and left chest wall herniation.

Open surgery remains an essential alternative for descending thoracic aortic aneurysms repair when anatomical constraints preclude endovascular intervention. We present the case of a 63-year-old woman with a complex pseudoaneurysm located at the junction of the distal aortic arch and proximal descending aorta (zones 3/4), approximately 7 mm distal to the origin of the left subclavian artery. The absence of a proximal landing zone rendered thoracic endovascular aortic repair unfeasible. A limited left thoracotomy was performed at the fourth intercostal space. Cardiopulmonary bypass was established with femoral venous and double arterial cannulation (aortic arch and distal thoracic descending aorta). A debranching bypass to the left subclavian artery was created using an 8 mm graft. After proximal and distal clamping, the pseudoaneurysm was resected and replaced with a bevelled 32 mm Dacron graft. Long-shafted instruments under video-assistance enabled precise dissection despite limited exposure and dense adhesions. The patient had an uneventful recovery, with no neurological complications and timely discharge. This case illustrates that open aortic repair can be safely and effectively performed through less invasive access in anatomically complex situations. Incorporating modern techniques allows the refinement of open surgery, preserving its relevance in contemporary thoracic aortic management.

This video tutorial presents the case of surgical correction of left outflow tract obstruction after atrioventricular septal defect repair. The left outflow tract obstruction was presented as a fixed fibromuscular membrane combined with accessory tissues from the left atrioventricular valve. The surgical correction included fibromuscular membrane resection combined with myotomy and resection of additional tissues arising from the atrioventricular valve. The repair was conducted via a transaortic approach. Post-operative echocardiography demonstrated a good result of the surgery without flow acceleration across the left ventricular outflow tract and minimal aortic valve insufficiency. The patient is doing well at 7 months follow-up.

This video tutorial explains how to treat an aortic aneurysm affecting the arch, descending, and thoracoabdominal segments, in the presence of an anatomical aortic arch variation. The procedure involves replacing the entire aortic arch and ascending aorta using the classic elephant trunk technique, creating a platform for a planned staged endovascular treatment. Special emphasis is placed on cerebral protection strategies, including preservation of an anomalous left vertebral artery and special reinforcement of a distal arch anastomosis. The presence of an anomalous artery arising directly from the aortic arch increased the technical difficulty, requiring customized revascularization to ensure appropriate left posterior cerebral circulation. This case reinforces the idea that open techniques can be safe for selected elderly patients with complex anatomies, highlighting the importance of tailored strategies and careful surgical execution.

The right transaxillary direct-view approach offers substantial advantages over conventional sternotomy when dealing with mitral valve pathology, including reduced post-operative pain, faster recovery and preserved respiratory function. However, its application in patients with complex thoracic deformities remains limited. We report a minimally invasive mitral valve repair in a young woman with severe chest wall deformity and suspected connective tissue disorder. Thorough pre-operative imaging evaluation and tailored surgical planning are crucial to ensure procedural safety and optimal outcomes. Once pre-operative assessment was completed, the procedure was smoothly performed according to our standard technique. Hence, this experience supports the feasibility and safety of the transaxillary approach in selected patients with thoracic deformities, providing excellent functional and cosmetic results, and enhancing recovery.

Ectopic parathyroid adenomas present a diagnostic and surgical challenge, particularly when located in anatomically complex regions such as the middle mediastinum. This report describes the case of a 76-year-old male with primary hyperparathyroidism caused by a parathyroid adenoma situated anterior to the oesophagus and beneath the aortic arch. Robotic-assisted thoracoscopic resection enabled precise, minimally invasive excision with successful post-operative biochemical resolution. This case highlights the evolving role of robotic techniques in endocrine and thoracic surgery.

A 67-year-old female presented with progressive dysphagia to solids and liquids. Imaging was concerning for end-stage achalasia with multiple failed attempts at pneumatic dilation. An outside hospital recommended oesophagectomy, but she came to our clinic for a second opinion. Computed tomography revealed tortuous megaoesophagus measuring up to 7 cm. Barium swallow revealed aperistalsis. Oesophageal manometry revealed an elevated integrated relaxation pressure, 100% failed peristalsis and panoesophageal pressurization in >20% of swallows, consistent with type II achalasia. We recommended a robotic Heller myotomy and Dor fundoplication. The patient was positioned supine with four 8 mm ports across the mid-abdomen. The pars flaccida was opened to access the right crus and oesophageal hiatus. The phreno-oesophageal ligament was taken down and the dissection was carried cephalad into the mediastinum. The greater sac was opened and the short gastric vessels and gastrosplenic ligament were taken down. The gastro-oesophageal junction fat pad was resected. A myotomy was created using a robotic hook without energy extending 6 cm on the oesophagus and 2 cm over the stomach. Modified Dor fundoplication was completed using four interrupted sutures. The patient was given a soft diet and discharged on post-operative Day 1. She subsequently had complete resolution of her dysphagia.