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

This case report presents the successful surgical management of a 34-year-old male who had blunt chest trauma resulting in a left atrial appendage tear after a traffic accident. He arrived at the emergency department 30 minutes post-injury in a gasping state, showing signs of hypovolemic shock, tachycardia (132 bpm), hypotension (blood pressure 88/48 mm Hg) and decreased breath sounds on the left side. The initial management included fluid resuscitation and the insertion of an intercostal drain, which drained 1.2 litres of blood. After the initial fluid resuscitation, haemodynamic stability was achieved with no further drainage from the chest tube. A computed tomography scan revealed haemothorax, bilateral rib fractures, right clavicular and scapular fractures and no active contrast extravasation. However, in the intensive care unit, the chest tube drainage suddenly increased to 250-300 ml/hour with escalating vasopressor requirements. An emergency left chest exploration was performed using thoracoscopy, which revealed significant blood clots and active bleeding from a pericardial defect, leading to conversion to an antero-lateral thoracotomy. The left atrial appendage tear was identified and repaired, achieving complete haemostasis. Postoperatively, the patient stabilized with ongoing intensive care management. This case underscores the challenges in managing traumatic cardiac injuries and highlights the critical need for timely surgical intervention to enhance survival outcomes in severely injured patients.

Open surgical conversion after debranching thoracic endovascular aortic repair in young patients with connective tissue disease is a formidable challenge, posing a high risk of cerebral air embolism. We report a case and describe a novel neuroprotection strategy to mitigate this risk. A 41-year-old female with connective tissue disease presented with a rapidly expanding 62-mm descending thoracic aortic aneurysm, five years after an initial debranching thoracic endovascular aortic repair. Following a staged oophorectomy for a borderline ovarian tumour, she underwent definitive open aortic repair. The operation was performed via a left thoracotomy with the patient under deep hypothermic circulatory arrest. To prevent air entry into the non-anatomical arch vessels, retrograde cerebral perfusion was initiated to establish positive venous pressure before the institution of selective antegrade cerebral perfusion. The stent graft was subsequently explanted, and the aorta was reconstructed. The procedure was completed successfully. The patient's postoperative course was uneventful, and she was discharged without any neurologic deficits. The proactive use of retrograde cerebral perfusion prior to selective antegrade cerebral perfusion is a simple, safe and effective technique to prevent catastrophic cerebral air embolism during complex open conversions. This case also highlights concerns regarding the long-term durability of thoracic endovascular aortic repair in young patients with connective tissue disease.

The Berlin Heart EXCOR biventricular assist device was used as a bridge-to-transplant strategy in a six-year-old girl with severe restrictive cardiomyopathy. An orthotopic heart transplant was performed after full recovery of stable end organ function had been achieved. After a re-sternotomy and the release of adhesions, cannulation for the heart-lung machine was achieved centrally, and the EXCOR device was removed. After left atrial and aortic anastomoses, reperfusion of the donor organ was begun, and the pulmonary artery and caval anastomoses were performed on the beating donor heart.

Oesophageal lipoma is a benign oesophageal tumour accounting for less than 1% of all the gastrointestinal lipomas. The spindle cell variant of oesophageal lipoma is an even rarer entity. Histologically it is characterized by the presence of varying amounts of mature fat, uniform spindle cells and collagen. To the best of our knowledge, only two cases of spindle cell lipoma (SCL) of the oesophagus have been reported so far. Herein, we present a case of a 52-year-old lady who was evaluated for dysphagia. Oesophago-gastroscopy showed a submucosal mass on the posterolateral wall of the oesophagus on the right side arising at 18-20 cm from incisors. Biopsy was suggestive of squamous hyperplasia with no evidence of dysplasia or malignancy. On computerized tomography (CT) scan of the chest, the mass measured 11.2x3.2x3.3 cm and was seen to extend from the post-cricoid to the infra-carinal region. In view of the major intrathoracic extent, she underwent robotic trans-thoracic excision of the oesophageal lesion. The final histopathology report confirmed SCL of the oesophagus. Immunohistochemical examination was positive for CD 34 and negative for desmin and MDM2. Complete excision of the lesion remains the standard treatment. It is essential to establish a precise diagnosis of SCL of the oesophagus and rule out malignancy.

Mitral-aortic intervalvular fibrosa pseudoaneurysm is a rare but potentially fatal complication, most commonly arising from infective endocarditis or a prior cardiac operation. Rupture of a mitral-aortic intervalvular fibrosa pseudoaneurysm constitutes a surgical emergency and presents considerable technical challenges, with reported early mortality rates between 20% and 30%. We report the case of a high-risk 72-year-old man with a history of two prior cardiac operations who presented with a contained rupture of a mitral-aortic intervalvular fibrosa  pseudoaneurysm and an aortic root abscess. Surgical management involved mitral-aortic intervalvular fibrosa reconstruction using a double-layer bovine pericardial patch within a Commando operation with a modified bio-Bentall procedure and coronary artery reimplantation via a Cabrol procedure. This integrated approach enabled complete debridement of the infected aortic root tissue and successful repair of the mitral-aortic intervalvular fibrosa defect, highlighting the value of combining these complex techniques in select high-risk reoperative settings.

Major infections remain a leading cause of readmission and reduced quality of life in patients with a durable left ventricular assist device. The driveline exit site is most commonly affected, and surgical management of severe driveline infections becomes necessary when conservative therapy of intensified dressing changes and antibiotic therapy fails. We present a standardized approach involving the transposition of the driveline with subsequent omentoplasty. The procedure aims to eradicate chronic infection, reduce microbial reservoirs by removing velour coverings and leverage the omentum's anti-inflammatory properties.

Tracheal resections are uncommon procedures in children. A tracheal resection is usually indicated for short-segment tracheal stenosis or tracheal tumours. A tracheal resection is very demanding, and success demands a collaborative effort from the anaesthesiologist, the ear, nose, and throat surgeons and the pulmonologist. Up to 50% of the trachea can be safely resected with good preoperative and intraoperative planning. The surgical approach to the trachea depends on the location and the extent of the lesions. In this case report, we describe the upper tracheal resection with an end-to-end anastomosis through a cervical incision in an 8-year-old child who presented with a large upper tracheal tumour causing near total occlusion of the trachea. The histopathological analysis of the mass indicated it was a schwannoma.

We present a 3.7-kg neonate with a foetal diagnosis of hypoplastic left heart syndrome who underwent stage I Norwood palliation using two technical modifications. We reconstructed the aortic arch and the aorto-pulmonary connection by following the Birmingham technique. The source of pulmonary blood flow was provided via a right ventricular-to-pulmonary artery shunt (Sano). A novel modification to the Sano conduit is demonstrated that we believe is more anatomical and physiologic. The composite Sano conduit was constructed using a 5-mm externally reinforced polytetrafluoroethylene graft connected to a 7-mm aortic homograft valve. The homograft valve was placed at the right ventricular end of the Sano conduit. We believe this design mimics a more normal anatomical right ventricular-to-pulmonary arterial connection and will help preserve the single ventricle function due to the lack of free pulmonary regurgitation.

Total arterial, anaortic, off-pump coronary artery bypass grafting is seen by many as a complex, specialized operation; however, when broken down into its component parts, it can be approached as multiple reproducible techniques that all trainees should master. These components include skeletonized mammary harvest, construction of composite arterial grafts and off-pump cardiac surgery. In this video tutorial, we describe step-by-step approaches to each of these elements and demonstrate how these principles come together to facilitate an excellent surgical outcome for the patient: revascularization of all diseased coronary arteries with arterial grafts while avoiding arresting the heart or aortic manipulation.

Coronary artery aneurysms are exceedingly rare and are most often discovered incidentally. Rupture of such aneurysms is even more uncommon. In this case report, we describe an 82-year-old patient who presented with sudden-onset chest pain and was diagnosed with a fissurating aneurysm of the right coronary artery. The aneurysm was associated with a congenital abnormality of the coronary venous sinus return. The patient underwent emergency surgery. Given her advanced age, the surgical strategy focused solely on addressing the imminent risk of rupture. A 10-mm Gore-Tex graft was implanted because direct suture repair or vein grafting was deemed unsuitable. The patient recovered well postoperatively and was given dual antiplatelet therapy. At nine months of follow-up, she remains asymptomatic, with no recurrence of chest pain.