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

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.

Bicuspidization is a valid option for unicuspid aortic valve repair, in which creating symmetrical commissural orientation is essential for improved outcomes. However, the right coronary orifice often interferes with symmetrical attachment of the neocommissure. In a paediatric patient without aortic root dilation, we rotated the right coronary orifice clockwise by cutting out a triangular piece of the non-coronary sinus wall and augmenting it between the left and right coronary sinuses. A neocommissure with patching was sewn to the left side of the right coronary orifice, and the symmetrical bicuspidized configuration was adjusted in a standardized fashion according to the cusp effective height measurement.

Despite the prognostic benefits for patients, surgical resection following nivolumab combined with platinum-based chemotherapy is technically challenging due to the inflammation or fibrosis in the thoracic cavity, particularly around the hilar structures. Performing this complex surgical resection using a minimally invasive approach requires the advantages offered by robotic surgery, including a high-definition 3-dimensional surgical view, precise, tremor-free motion and articulated forceps, which facilitate safe resection following neoadjuvant immunochemotherapy. In this video tutorial, we demonstrate a robotic right lower lobectomy performed after neoadjuvant nivolumab combined with platinum-based chemotherapy, highlighting the specific techniques and nuances involved. The console time was 138 minutes, with minimal blood loss. The patient's postoperative course was uneventful; the chest tube was removed on postoperative day (POD) 1, and the patient was discharged on POD 2. The final pathological report revealed pTisN0M0, stage 0, squamous cell carcinoma.

We present a case report detailing the surgical intervention in a patient with prosthetic aortic valve endocarditis complicated by a paravalvular abscess extending to the mitral-aortic fibrosa. Urgent surgery was required due to severe detachment of the prosthetic aortic valve, marking her third cardiac surgical procedure. Notably, preoperative imaging revealed the presence of a persistent left superior vena cava, a rare vascular anomaly requiring specialized cannulation techniques. The surgical approach involved removal of the infected tissue and prosthetic valve, followed by replacement with a cryopreserved aortic homograft, chosen for its anatomical adaptability.

Carinal reconstruction remains a technically challenging procedure for thoracic surgeons due to the complexity of airway resection and management. This is typically performed in the setting of tumour resection affecting the carina and distal trachea. Airway management of patients undergoing surgical resection of tumours involving the carina is highly challenging. This is due to an open, shared airway and the need for single-lung ventilation to facilitate surgery. Common modalities used for intraoperative ventilation include cross-table ventilation, veno-venous extra-corporeal membrane oxygenation and cardiopulmonary bypass. Cardiopulmonary bypass is usually avoided due to the requirement of full heparinization, which increases the demands of a technically challenging procedure, in addition to its contraindication in oncological resections. Extra-corporeal membrane oxygenation is not readily available in most thoracic units. This leaves cross-table ventilation, which is commonly used for open thoracotomy and sternotomy cases, but has never been reported for minimally invasive procedures.  Specifically, to the best of our knowledge, cross-table ventilation has never been used for minimally invasive robotic carinal reconstruction. We present a step-by-step video tutorial in performing surgical resection of a mediastinal tumour that was found invading the carina. This was performed in a young patient who underwent carinal reconstruction using a novel technique combining cross-table ventilation and robotic-assisted surgery.

In this video tutorial case report, we show how to perform an open surgical correction of an ascending aortic aneurysm in a 74-year-old patient requiring concomitant aortic valve and hemiarch replacements, presenting with symptomatic stenosis of the aortic valve and moderate dilatation of the ascending aorta.

Our objective is to describe our approach for a case of subacute on top of chronic thromboembolic disease and highlight operative learning points. Prior to incision, appropriate monitoring equipment, including an arterial line, Swan-Ganz catheter, brain saturation monitor and bispectral index monitor, is placed for proper management of haemodynamics. Sternotomy was performed, and the ascending aorta was cannulated, followed by bicaval cannulation for venous drainage. The patient was cooled to deep hypothermia. Once target temperature was achieved, circulatory arrest commenced. The left pulmonary artery was opened and the subacute component was removed without disrupting the plane of the chronic thromboembolic disease. An endarterectomy plane was then created proximally and dissected into the distal segmental/subsegmental branches. Once the endarterectomy was completed, the left pulmonary artery was closed. Circulation was resumed for end-organ perfusion. Once the right pulmonary artery was ready for dissection, circulatory arrest was restarted. Similarly to the left side, the subacute component was removed without disrupting the plane of the chronic thromboembolic disease. An endarterectomy plane was then created proximally and dissected into the distal segmental/subsegmental branches. Circulation was then resumed. Once rewarmed to 35.5°C, the patient was decannulated and the sternum was closed.

Heart transplant remains the gold standard treatment for patients with end-stage heart failure. However, given the limited availability of donor hearts, alternative approaches and strategies are required. The development of a variety of mechanical circulation support options, including left ventricular assist devices and total artificial heart, have allowed improved quality of life and eventually have facilitated a bridge to heart transplantation strategies for certain patients. However, the presence of an intracorporeal left ventricular assist device poses a technical challenge at the time of heart transplantation. In this video tutorial, we describe the surgical strategy and removal technique for a patient who had received a HeartMate 3 (Abbott, North Chicago, IL, USA) using a classic implantation technique via sternotomy, who underwent concomitant orthotopic heart transplant.

Systolic anterior motion is characterized by the displacement of the anterior mitral leaflet towards the left ventricle outflow tract. Iatrogenic systolic anterior motion occurs after mitral valve repair as a result of mitral annuloplasty. Possible causes include excess height of a redundant posterior mitral leaflet and/or the use of an undersized ring. The condition is usually diagnosed after weaning from cardiopulmonary bypass by transoesophageal echocardiography. Apart from conservative measures, the treatment of systolic anterior motion may require the restoration of cardiopulmonary bypass and further surgical valve repair. Strategies for systolic anterior motion correction include an edge-to-edge repair or the use of a larger annuloplasty ring. In this tutorial, we present two ways of reducing posterior leaflet height as a simple option to move the leaflet coaptation more posteriorly.