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

Three-dimensional (3D) guided robotic-assisted thoracic surgery is increasingly recognized as the pioneering approach for the most complex of pulmonary resections, offering high-definition 3D visualization, enhanced instrument augmentation and tremor-free tissue articulation. Compared with open thoracotomy, the robotic platform is associated with reduced peri-operative morbidity, shorter hospital admissions and faster patient recovery. However, sublobar resections such as segmentectomies remain anatomically and technically demanding, particularly in the context of resecting multiple segments, as showcased in this right S1 and S2 segmentectomy. The integration of 3D reconstruction imaging allows for meticulous pre-operative assessment of bronchovascular anatomy, enabling tailored surgical planning and more accurate dissection. Despite these clear advantages, the routine application of 3D virtual modelling in thoracic surgery is still underutilized and remains insufficiently represented in the existing body of evidence. This video tutorial is the fourth entry in the "Segmentectomies Made Easy" atlas and demonstrates a robotic right S1 and S2 segmentectomy performed for a primary pulmonary lesion in the S1 segment. Pre-operative 3D imaging revealed the distinct anatomical structures, which played a pivotal role in shaping the dissection strategy. The tutorial provides a clear, step-by-step account of the procedure, from port placement to vascular resection and complex anatomical identification, emphasizing how 3D visualization enhances surgical accuracy, improves intra-operative decision-making and optimizes outcomes in robotic-assisted thoracic surgery.

Complete detachment of the aortic root following a Bentall procedure is an exceptionally rare complication. The vast majority of reported cases are secondary to prosthetic valve endocarditis or underlying vasculitis. Currently, the most reliable treatment for aortic root dehiscence-particularly in the context of prosthetic valve endocarditis-is repeat root replacement, typically via a second Bentall procedure or with the use of a homograft or allograft. However, re-root replacement is associated with significantly higher morbidity and mortality compared to the initial operation. In cases without evidence of endocarditis or known vasculitis, augmentation of the detached aortic root using a short-segment Dacron tube graft has been shown to be a safe and effective alternative. This technique avoids the need for coronary button mobilization and reimplantation. In this presentation, we describe the surgical management of a patient who experienced complete aortic root detachment after a Bentall procedure, treated via elongation of the left ventricular outflow tract.

Kommerell's diverticulum (KD) combined with a right-sided aortic arch (RAA) and an aberrant left subclavian artery (ALSA) is a rare congenital vascular anomaly causing significant compressive dysphagia. Treatment options, including open surgery, thoracic endovascular aortic repair and hybrid approaches, are debated due to anatomical complexities. We report a 48-year-old female with dysphagia from symptomatic KD, RAA and ALSA, clearly delineated by preoperative computed tomography angiography. A right thoracotomy enabled aortic arch replacement. Deep hypothermic circulatory arrest and retrograde cerebral perfusion were utilized for neuroprotection. KD was resected, and ALSA was reconstructed via interposition graft, anastomosed end-to-side to the main prosthetic graft. Meticulous dissection, including division of the ligament on the diverticulum's greater curvature, and careful handling of fragile aortic tissue with felt-pledgeted sutures were key. The patient recovered uneventfully, with complete dysphagia resolution and discharge on postoperative Day 10, without complications. Right thoracotomy offers excellent exposure for comprehensive repair of complex KD with RAA and ALSA. This case demonstrates the feasibility and effectiveness of open surgical repair with meticulous technique and cerebral protection for favourable outcomes in such rare and challenging vascular anomalies.

Triangular resection is an effective repair technique for isolated segmental posterior leaflet prolapse in mitral valves at low risk for systolic anterior motion. It is applicable in the majority of such cases, is low risk, and has excellent long-term durability. Its simplicity and efficacy make it an essential part of every mitral surgeon's armamentarium. Herein we present our robotic approach to triangular resection, highlighting subtle adaptations from the open technique.

Optimal exposure in mitral valve surgery is crucial for procedural success. Robotic techniques provide unparalleled visualization when ports and retraction sutures are positioned precisely. Here, we outline our standardized approach for patient positioning, marking and port placement, derived from extensive institutional experience. Adherence to this technique reliably ensures excellent valve exposure and facilitates reproducible surgical outcomes.

Robotic mitral valve surgery requires pericardiotomy via the right chest. Opening more anterior than traditionally described enhances visualization of the right ventricle, obviates the need for anterior pericardial stays, and keeps the lung out of the way posteriorly. We prefer to utilize an external cross-clamp for aortic occlusion due to its simplicity and reproducibility and now use a detachable clamp, which avoids potential conflicts with robotic instruments. Herein we describe our current technique for these important components of robotic valve surgery.

There are several important differences when positioning and placing ports for robotic mitral surgery in female patients. Herein we demonstrate our technique while highlighting some important tips and tricks. This approach almost universally results in a perfect view, as well as a scar that is cosmetically pleasing.

The David procedure has been extensively studied as an elective treatment when valve anatomy and function permit valve-sparing aortic root replacement. This approach is particularly beneficial in young patients who also require mitral valve repair and treatment for mitral annular disjunction. This video tutorial provides a step-by-step guide to the David V procedure in a female patient with Marfan syndrome, presenting with an aortic root aneurysm, severe mitral regurgitation and mitral annular disjunction.

We present a 62-year-old female with severe aortic valve regurgitation and a ruptured large sinus of Valsalva aneurysm. The aneurysm was resected in its entirety. A single-leaflet aortic valve reconstruction combined with a left coronary sinus aortic root replacement (hemi-Yacoub procedure) was performed with success.

Concomitant aortic root and pulmonic root aneurysms secondary to giant cell arteritis are extremely rare. We present a case of a patient with giant cell arteritis who underwent concomitant valve-sparing aortic root replacement and valve-sparing pulmonary root replacement along with tricuspid valve repair.