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

Ebstein's anomaly is a rare congenital heart defect characterized by tricuspid valve malformation and right ventricular myopathy. The "cone procedure," introduced by Dr. José Pedro da Silva, represents a major advancement in the repair of Ebstein's anomaly, achieving near-anatomical tricuspid valve reconstruction. We describe the case of a 23-year-old-female with Carpentier type B Ebstein's anomaly, severe tricuspid regurgitation and Wolff-Parkinson-White syndrome, who underwent cone reconstruction combined with right ventricular resection. Detailed preoperative imaging guided the procedure, ensuring precise leaflet mobilization, delamination and cone creation. The atrialized right ventricular portion was reduced via triangular resection, preserving right ventricular geometry. An annuloplasty ring stabilized the repair. Postoperatively, the patient demonstrated excellent recovery, with trivial regurgitation and preserved right ventricular function confirmed at the one-year follow-up. This case highlights the reproducibility and effectiveness of the cone repair, supporting its role as the primary surgical approach for Ebstein's anomaly. Key factors for success include meticulous leaflet delamination, ensuring a complete 360° cone structure and maintaining RV geometry. Although long-term outcomes require further evaluation, the cone procedure offers superior valve competence and symptom relief compared to traditional repairs, minimizing the need for reoperation.

Pre-operative planning is crucial before minimally invasive lung resection. 3D reconstruction software has become an essential tool to identify anatomical variations and anticipate surgical difficulties. Nevertheless, a misinterpretation can make surgery more challenging, especially in the presence of anatomical anomalies such as a cleft left upper lobe. A 74-year-old woman was treated for an adenocarcinoma in the left upper lobe. Multidisciplinary discussion recommended robotic assisted left upper lobectomy. At first, pre-operative 3D reconstruction showed no anomalies. Intra-operatively, dissection revealed an unusual culmen bronchus (B1+3) arising posterior to the pulmonary artery trunk, so-called "cleft" left upper lobe or "eparterial" bronchus. This lesser-known variant had not been identified pre-operatively by automated software, creating temporary intra-operative uncertainty. The dissection was adapted, and lobectomy was successfully completed. A retrospective analysis of the 3D model made it possible to understand the error and to better appreciate the anatomical relationships of this bronchus. The post-operative course was uneventful and at 8-month follow-up the patient remained recurrence-free. This case highlights the importance of pre-operative imaging analysis, the limitations of automated 3D reconstruction, and the need for surgeon awareness of rare bronchial variants to ensure efficiency during minimally invasive surgery.

Pulmonary valve pathology is the most common entity encountered in adults with congenital heart disease. Most of these patients have undergone a previous interventional cardiac catheterization procedure or were operated upon during childhood and later on had persistent or recurrent pulmonary valve pathology that warrants re-interventions. The majority of these adulthood re-interventions are in the form of pulmonary valve replacement, and while there are currently several options for replacement of the pulmonary valve, none is satisfactory and will create a need for future procedures considering the young age of these patients. In this video tutorial, we present another option for these patients, which is pulmonary valve reconstruction using the patient's own autologous pericardium.

Three-dimensional guided robotic-assisted thoracic surgery is increasingly recognized as a leading technique for undertaking the most complex pulmonary resections, providing high-definition three-dimensional visualization, advanced instrument control and tremor-free tissue handling. Compared with open thoracotomy, the robotic platform offers reduced perioperative complications, shorter hospital stays and faster patient recovery. Nevertheless, sublobar resections, such as segmentectomies, remain both anatomically intricate and technically challenging, particularly when resecting multiple segments, as in this left S1 and S2 segmentectomy. Incorporating three-dimensional reconstruction imaging facilitates comprehensive preoperative evaluation of bronchovascular anatomy, enabling tailored operative planning and therefore more precise dissection. Despite these benefits, the consistent use of three-dimensional virtual modelling in thoracic surgery is still limited and under-represented within the current literature. This video tutorial constitutes the fifth entry in the Segmentectomies Made Easy atlas and showcases a robotic left S1, S2, S3 trisegmentectomy performed for a primary pulmonary lesion in the S1 segment in the left upper lobe. Preoperative three-dimensional imaging identified the lesion to be deeply centrally located and greatly informed our surgical approach. This video tutorial delivers a structured, step-by-step overview of the operation, from port placement through to vascular division and extensive complex anatomical delineation, highlighting the ways in which three-dimensional visualization dictates surgical precision, enhances intraoperative decision-making and contributes to optimized outcomes for robotic-assisted thoracic surgery.

This video tutorial demonstrates the surgical repair of a bicuspid aortic valve in a 45-year-old male patient with severe aortic regurgitation due to annular dilatation and prolapse of the fused cusp. The procedure included external annuloplasty to stabilize and downsize the annulus, and cusp plication to restore effective height and durable coaptation. The repair resulted in a competent native valve with preserved geometry. It highlights reconstructive strategies as a durable alternative to valve replacement.

Annular plication is a fundamental technique in mitral valve repair, forming a core component of classic quadrangular resection by enabling tension-free re-approximation of the cut leaflet edges. While smaller resections are more commonly performed in the current era, annular plication remains essential in selected cases. We describe a modification of the originally described technique that allows efficient, accurate application while preserving its underlying surgical principles.

Aortic coarctation is typically diagnosed in infancy, but some cases present in adulthood, posing significant risks including aortic dissection, myocardial infarction and heart failure. In adults requiring complex aortic or cardiac interventions, extra-anatomical ascending-to-descending aortic bypass via median sternotomy is a preferred surgical option due to its reduced risk of spinal cord ischaemia and recurrent laryngeal nerve injury. We present the case of a 55-year-old woman with lifelong hypertension and severe headaches. Transthoracic echocardiography revealed a significant narrowing at the aortic isthmus with elevated peak velocity and pressure gradients. Contrast-enhanced computed tomography confirmed 80% narrowing without aneurysmal changes. The patient underwent an extra-anatomical bypass using a 16mm interposition graft via median sternotomy. The graft was routed behind the left ventricle and over the left pulmonary artery to connect the ascending and descending aorta. Intra-operative haemodynamic improvement was immediate, with normalization of upper and lower body pressures. Post-operative imaging confirmed correct graft positioning without stenosis or kinking. The patient recovered uneventfully and was discharged on post-operative Day 12. This case demonstrates the safety and effectiveness of extra-anatomical bypass via sternotomy in adult coarctation, offering a viable alternative to thoracotomy in anatomically and surgically complex scenarios.

Repair of complete atrioventricular septal defects continues to be a challenge. Several techniques have been described such as the single-patch, the modified single-patch and the two-patch technique. Each has its own pros and cons, and no technique is free from reoperation. Routine augmentation of the left atrioventricular valve during the repair has also been proposed; however, a repeat operation for recurrent left atrioventricular regurgitation continues to be a major concern. In this report, we describe a new strategy for the repair of a complete atrioventricular septal defect that combines the basics of several of the previously described techniques, eliminates some of the anatomical factors behind future left ventricular outflow tract obstruction and may improve competence of the left atrioventricular valve, and has the potential of decreasing the reoperation rate on both the left atrioventricular valve and the left ventricular outflow tract.

Sinus of Valsalva aneurysms are rare cardiac anomalies with life-threatening potential when ruptured. While most arise from the right coronary sinus and rupture into right-sided chambers, left-sided ruptures are exceptionally uncommon and surgically challenging. We report a 57-year-old male with multiple comorbidities and newly diagnosed stage 4 follicular lymphoma who presented with New York Heart Association class IV heart failure. Imaging revealed a large pseudoaneurysm of the left sinus of Valsalva with perforation into the left atrium and ventricle, disruption of the aorto-mitral curtain, and severe mitral regurgitation. A multidisciplinary team recommended surgery prior to chemotherapy. The operation included a mitral valve repair with autologous pericardial patch, reconstruction of the aorto-mitral curtain, aortic valve replacement, and ascending aortic replacement with a Dacron graft. Post-operatively, the patient developed tamponade, bacteraemia and required prolonged intensive care, but ultimately stabilized and proceeded with lymphoma therapy, and is currently doing well. This case highlights the rarity and complexity of left-sided sinus of Valsalva aneurysm rupture involving multiple cardiac structures. Definitive surgical repair remains the gold standard, and a multidisciplinary approach is essential in optimizing outcomes for high-risk patients with significant comorbidities.

Folding plasty is a valuable technique for reducing excessive posterior leaflet height and mitigating the risk of systolic anterior motion. It offers a simpler alternative to the classic quadrangular resection with sliding plasty and has demonstrated comparable long-term durability when applied in appropriate settings. We have adopted this technique widely and employ it frequently in both open and robotic mitral valve repair.