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

The treatment of pectus excavatum has historically been based on two main surgical techniques: the Ravitch procedure and the minimally invasive Nuss procedure. Both have demonstrated effectiveness over the years and have become well-established options in clinical practice. However, in recent years, a new approach known as the Pectus Up technique has emerged as an innovative and less invasive alternative for the correction of this congenital chest wall deformity. In this video tutorial, we present the case of a young male patient treated using the Pectus Up system, highlighting the surgical steps, clinical outcomes and potential advantages of this novel method compared to traditional techniques.

Interventricular septal aneurysm represents a rare cardiac anomaly traditionally associated with ischaemic heart disease or healed congenital ventricular septal defects. In this report, we present the first documented case of robot-assisted surgical repair of an interventricular septal aneurysm. Our 47-year-old male patient presented with symptomatic heart failure secondary to moderate aortic stenosis and severe aortic regurgitation. During pre-operative evaluation, imaging revealed an incidental membranous interventricular septal aneurysm without an associated shunt. The patient underwent successful robot-assisted transthoracic patch repair of the septal aneurysm concurrent with aortic valve replacement. This case demonstrates the feasibility of robot-assisted repair for complex cardiac anomalies, potentially expanding the horizons of minimally invasive cardiac surgery.

Porcelain aorta, though rare, is often considered a contraindication for open surgery due to the risk of associated neurological complications due to calcium embolization. We present the case of a 70-year-old female with a prior 19mm bioprosthetic aortic valve replacement who, during routine follow-up, was found to have significant aortic valve stenosis, severely reduced leaflet mobility and a mean gradient of 40mmHg. Pre-operative computed tomography angiography revealed a calcified 'porcelain aorta'. Transcatheter aortic valve-in-valve replacement was not possible due to the small 19mm valve and small aortic sinuses, leading to referral for open aortic surgery.

Commissuroplasty is a simple yet highly effective technique to address prolapse involving the mitral commissures, which can otherwise be technically challenging to repair using traditional resection or neochordae. We demonstrate our robotic approach and highlight key technical nuances, indications and expected outcomes relevant to mitral surgeons.

Systolic anterior motion remains a recognized complication of mitral valve repair, for which sliding valvuloplasty was originally developed as a preventive strategy. This technique is used in patients with a broad area of posterior leaflet prolapse and excessive leaflet height. We demonstrate our modification of the classic sliding plasty, including further adaptations to enable its reliable and efficient application via a minimally invasive robotic approach.

Cardiac fibromas are rare benign myocardial tumours, most commonly detected in infants and children. Presentations in adolescents are uncommon but clinically significant due to the associated arrhythmic risk. We report a case of a young female who presented with syncope and was subsequently diagnosed with a left ventricular fibroma on cardiac magnetic resonance imaging (MRI). The tumour was located near the papillary muscles. Surgical excision was performed via a left ventriculotomy, carefully avoiding distortion of the mitral valve. This video tutorial demonstrates the surgical approach to an left ventricular fibroma, a definitive treatment aimed at mitigating the life-threatening arrhythmogenic risks associated with these tumours, while preserving the mitral valve.

Uniportal video assisted thoracoscopic surgery is a widely adopted method for lung resections. One of the main advantages quoted in favour of this minimally invasive technique is the violation of only a single intercostal space and hence less post-operative pain. Fissureless lobectomy decreases the chances of post-operative air leak, especially when fissures are poorly formed. Tumour-abutting parietal pleura can be managed with uniportal video assisted thoracoscopic surgery, with resection of the cuff of the parietal pleura around the tumour, to achieve a negative margin. This video tutorial demonstrates a fissureless right upper lobectomy, in the presence of significant adhesions and pleural infiltration.

Sternal dehiscence incidence ranges from 0.2% to 5%]. Risk factors include obesity, advanced age, use of bilateral internal thoracic arteries, diabetes mellitus and chronic obstructive pulmonary disease [1]. Traditional techniques with steel wires have been associated with dehiscence rates of up to 11.8% [2]. Utilizing titanium plates, the incidence of sternal dehiscence has reduced to 1.5% [3]. The STERN FIX Sternal Stabilization System is a biocompatible carbon-fibre reinforced poly-ether-ether-ketone tool constituting two components, both with a curved arm that embraces the sternum at the level of an intercostal space and does not perforate the intercostal fascia, reducing the retrosternal bleeding [4]. The sternal closure is performed following five steps: sizing using a gauger (device available for sternal bone thicknesses between 9.5 and 17mm); marking the selected intercostal space bilaterally to allow the passage of the device; placement of both device parts; closure of the device; and cutting the excess segment. The sternal closure is complemented with cerclage wire. The first results are very satisfactory, with 0% sternal dehiscence at 6 months on 30 patients [5], comparable to those achieved by adopting the Robicsek technique [6]. We present a video tutorial case of ministernotomy closure using the STERN FIX system.

Infectious aortitis is an uncommon but life-threatening condition due to its potential to cause mycotic aneurysms, which may lead to vascular rupture. When signs of vascular disruption are present, isolated antibiotic therapy is insufficient, requiring combined open surgical resection of the infected aorta. A 68-year-old woman diagnosed with Streptococcus pneumoniae aortitis is presented. Multiple saccular mycotic aneurysms of varying sizes along the thoracoabdominal aorta, with intense fluorodeoxyglucose uptake on positron emission tomography scan were present in conjunction with extravascular infectious sources. Urgent Crawford extent II thoracoabdominal aortoiliac reconstruction was indicated. Due to extensive atheromatosis of the proximal descending aorta and the relative contraindication to cerebrospinal fluid drainage (spondylodiscitis), repair was performed with profound hypothermia (18°C). Renal protection was achieved using Custodiol and visceral perfusion maintained with cold blood. Each visceral artery was individually reimplanted using a 26mm multibranched graft. Distal reconstruction was completed with a bifurcated prosthesis, given the presence of severe aortic bifurcation calcification. Despite negative intra-operative cultures, histopathology confirmed extensive aortic inflammatory/reparative findings. Post-operative recovery was uneventful. At 1-year follow-up, the patient remains in good condition, with no clinical recurrence, no pathological positron emission tomography/computed tomography uptake, and a stable aortic repair without suppressive antibiotics.

We present the technical steps and pitfalls of minimally invasive resection of a recurrent subaortic membrane via a redo right axillary thoracotomy in a child.