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

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.

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.