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

The Berlin Heart EXCOR is used in paediatric patients with ventricular failure for temporary support as a bridge to a cardiac transplant or, occasionally, as a bridge to ventricular recovery. Neonates, infants and children who are supported with ventricular assist devices while gaining weight also have an increased demand for cardiac output while supported. Some patients might need a few pump exchanges to meet circulatory needs while growing. In this case report, we present the step-by-step technique for exchanging and upsizing the Berlin Heart EXCOR single ventricle-ventricular assist device in a 5-kg baby.

Ischaemic spinal cord injury remains a significant challenge in thoracoabdominal aortic repairs. Modern techniques have reduced spinal cord injury rates yet managing patients during and after thoracoabdominal aortic repairs remains complex. This article outlines our comprehensive approach to the prevention of spinal cord injuries in open thoracoabdominal aortic repair operations, focusing on the placement of cerebrospinal fluid drain and intraoperative strategies to enhance spinal cord protection. Preoperative planning involves thorough patient assessment, prehabilitation and nutritional support, detailed imaging review, thorough operative planning and patient blood management. Intraoperative measures include the use of neuromonitoring techniques like near-infrared spectroscopy and motor evoked potentials, as well as cerebrospinal fluid drainage together with blood pressure management to optimize spinal cord perfusion. Postoperative management focuses on maintaining haemodynamic stability with high mean arterial pressure, along with close monitoring and management of the cerebrospinal fluid drain to improve spinal cord perfusion. Additionally, thromboelastography-guided strategies are crucial for optimizing coagulation and addressing postoperative bleeding complications. The goal of this multifaceted approach is to minimize the risk of spinal cord injury, thereby improving patient outcomes and reducing the incidence of postoperative paraplegia. Our video tutorial shows some of our preoperative and intraoperative techniques for spinal cord protection in thoracoabdominal aortic repairs.

Pulmonary sequestrations comprise a spectrum of congenital lung malformations, with abnormal lung tissue lacking connection with the tracheobronchial tree, supplied by an aberrant systemic artery. Until a few years ago, lobectomy was considered the standard treatment for intralobar pulmonary sequestration. However, minimally invasive sublobar resection gained a place as an interesting alternative therapeutic approach, guided by indocyanine green and computed tomography-based 3-dimensional anatomical models. Like pulmonary sequestrations,  pulmonary pseudosequestrations are a congenital lung malformation, but characterized by a normal lung tissue fed by systemic arterial branches. To the best of our knowledge, there are no published cases of pulmonary pseudosequestration combined with sequestration. We present a case of an intralobar pulmonary sequestration coupled with an adjacent pseudosequestration, resected using thoracoscopic surgery with the aid of a 3-dimensional anatomical model and indocyanine green.

Robotic-assisted thoracic surgery has emerged as a prominent technique for performing radical thymectomies in patients affected by early-stage thymic tumours. This technique is favoured because of its high ergonomics, superior image quality, enhanced instrument manoeuvrability and exceptional precision. Among the different surgical approaches developed, the unilateral and the bilateral intercostal approaches are the most widely diffused. The subxiphoid approach offers several advantages over these approaches, providing a wide visualization of the entire mediastinum and of both pleural cavities while enabling bilateral dissection through a single bilateral small intercostal incision. It brings an optimal central view of the mediastinum, easy control of both phrenic nerves and enhanced dissection at the level of the superior thymic horns and the left brachiocephalic vein, all while minimizing intercostal trauma. We present a robotic subxiphoid radical thymectomy using the da Vinci Xi platform, illustrated by a case involving a patient with a 5-cm thymoma close to the left phrenic nerve.

Findings in the present case underscore the potential of sutureless aortic valve utilization in patients with prior prosthetic root replacement, thereby obviating the need for high-risk procedures such as replacing a prosthetic root or reimplanting a coronary artery. A 75-year-old male who had undergone a Bio-Bentall operation with a bioprosthetic Trifecta valve for aortic regurgitation and annuloaortic ectasia eight years prior presented with symptoms of heart failure, notably dyspnoea, attributed to prosthetic valve dysfunction. Although a transcatheter aortic valve implant is often recommended, it was deemed unsuitable in this case due to a history of type B aortic dissection. Aortic valve replacement utilizing a sutureless Perceval valve with a Trifecta cuff as the valve ring was successfully performed through a repeat median sternotomy, which enabled aortic valve replacement via a higher than usual aortotomy with minimal adhesion dissection. Despite the inherent risks associated with a reoperation post-Bentall surgery, the duration of the procedure was notably short, with only 85 minutes required for cardiopulmonary bypass and 51 minutes for aortic clamping, resulting in an overall operating time of 198 minutes, thus highlighting the minimally invasive and safe nature of this approach.

It is generally accepted that the definitive treatment for irreparable aortic root disease is aortic root replacement with a valved conduit - the Bentall procedure. However, we try to follow a reparative strategy for all aortic root pathology whenever possible. Our "root-sparing" philosophy is achieved by restoration of physiological aortic root dimensions by the Florida sleeve technique and aortic cusp substitution by neocuspidization. The combination of both strategies allows for full reconstruction of the root, instead of its replacement. Our modification is called FLOZ, from "FLorida + OZaki".

We present the case of a failed papillary muscle approximation successfully treated using a totally endoscopic, robotic-assisted approach.

The patient had a unicuspid aortic valve with severe aortic stenosis and a mildly dilated and hypertrophied left ventricle with moderately impaired systolic function. Herein we demonstrate the technique of severely dysplastic unicuspid aortic valve repair in the neonatal period.

A 76-year-old patient with non-ST elevation myocardial infarction was admitted to our hospital. Coronary angiography revealed significant left main and two-vessel coronary artery disease. Preoperative testing indicated severe left ventricular dysfunction. The patient was scheduled for urgent off-pump coronary artery bypass grafting. Due to the low ejection fraction, an intra-aortic balloon pump was inserted in the operating theatre before sternotomy, to enhance the patient's haemodynamic stability during surgery. A 6 Fr introducer was inserted into the femoral artery under echocardiographic guidance. Using a 150-cm guidewire, the intra-aortic balloon catheter was advanced through the introducer to the descending thoracic aorta. The catheter's tip position, just distal to the origin of the left subclavian artery, was confirmed via transoesophageal echocardiography. The external part of the catheter was secured to the skin and connected to the balloon console. Therapy was initiated, and the inflation/deflation parameters were optimized. A double off-pump coronary artery bypass was performed via median sternotomy. The patient remained haemodynamically stable throughout the surgery, aided by the intra-aortic balloon pump, and careful volume and vasoactive management. The patient was extubated promptly, and the device was removed on the second postoperative day without complications.

A 70-year-old female patient was referred from a peripheral hospital to our department with an incidental finding of an intra-aortic mass. Chest access was gained by a median sternotomy, and visualization of the intra-aortic mass was achieved using epiaortic ultrasound. After systemic heparinization, arterial cannulation was performed in the distal aortic arch. The right atrium was cannulated; the patient was cooled to a target temperature of 22°C. With the patient under hypothermic circulatory arrest, a transverse aortotomy was performed 3 cm proximal to the brachiocephalic trunk, and prompt removal of the tumour was achieved. After establishing antegrade cerebral perfusion, proper visualization of the aortic wall was achieved, and no pathological alterations of the aortic wall were encountered. After closure of the aorta and complete rewarming, the patient was easily weaned from cardiopulmonary bypass. Chest closure was performed in the usual fashion. The postoperative course was uneventful, and the histopathological diagnosis was thrombus formation. Consequently, the patient was placed on lifelong phenprocoumon therapy.