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Bil Kirmani of the Liverpool Heart and Chest Hospital in the UK compares minimally invasive and open surgical approaches for aortic valve replacement. He presents a review comparing full to limited sternotomy and discusses the available data on anterior right minithoracotomy.This presentation was originally given during the SCTS Ionescu University program at the 2018 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs.
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  • Video
Aortic coarctation is one of the most common congenital anomalies. The incidence of coarctation of the aorta is 4 in 10,000 live births, accounting for 5–8% of the children with congenital heart defects (1). During adult life, the presentation of coarctation mostly represents re-coarctation following previous therapy or missed cases of native coarctation. Patients who have not had surgery are at risk of developing severe hypertension, stroke, aortic dissection, and congestive heart failure. Mean life expectancy when untreated is 35 years, and 90% of those patients die before the age of 50. There are different methods employed for the treatment of coarctation in adults, including surgical or percutaneous balloon angioplasty with or without stent placement, and medical therapy. The authors present a case of a 62-year-old woman with no known prior cardiac disease other than hypertension. During a workup for a neurological tumor, the diagnosis of an aortic coarctation was made. Surgery was needed for the neurological tumor, but the neurosurgeons refused to operate with the presence of coarctation because of possible hypoperfusion of the abdominal organs during surgery. Computed tomography (CT) scan of the aorta showed a coarctation with residual lumen of 3 mm and post-stenotic dilation and calcification of the descending aorta. The authors decided to do an extra-anatomical bypass via sternotomy because of faster recovery and less perioperative risks, and a percutaneous approach was deemed not feasible.The authors monitored a radial and a femoral artery line to evaluate pressure proximally and distally from the coarctation. They measured 180/80 mmHg radial and 100/50 mmHg femoral pressure. A classic sternotomy was performed. For arterial cannulation they used a split configuration with an Eopa 20 Fr cannula in the aorta and a second arteria 16 Fr cannula in the femoral artery placed percutaneously. A ProGlide™ system was put into place. This way, the abdominal organs could remain perfused at all times. Upon declamping the arterial lines, the authors could see an equalization of radial and femoral arterial pressure. They performed a bicaval venous cannulation to assess the anatomy optimally for positioning the bypass.The heart was luxated out of the pericardium using an apical suction device. The pericardial fold was opened and dissection of the descending aorta was performed. The esophagus was identified by moving the TEE probe up and down. After achieving good exposure, a side-clamp was positioned and a size 20 graft was sewn into the descending aorta using prolene 4.0. After thorough inspection for leakage, the pericardial fold was closed with a few stitches and the heart was put back in place. The graft naturally fell to the ventricular side. To measure the length of the graft, the heart was filled up to normal size. A side-clamp was placed on the ascending aorta and the proximal anastomosis was made using prolene 4.0. Patency of both anastomosises was checked and dissection was ruled out with perioperative TEE. After weening the patient from cardiopulmonary bypass, both arterial pressures were equal and the sternum was closed, leaving two chest drains. The patient was discharged six days postoperatively and had no perioperative complications.ReferencesAgarwala BN, Bacha E, QiLing C, Ziyad MH. Clinical manifestations and diagnosis of coarctation of the aorta.2009.Anagnaostopoulos–Tzifa A. Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol. 2007;48(5):290–295.
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Filmed at the 2018 EACTS Annual Meeting in Milan, Italy, Vinicius Nina of the University Hospital of the Federal University of Maranhão in Brazil moderates a discussion on approaches for success in humanitarian heart surgery. Dr Nina is joined by Marcelo Cardarelli of the Inova Children's Hospital in Falls Church, Virginia, USA, and William Novick of the University of Tennessee in the USA and Medical Director of the Novick Cardiac Alliance. The panel discusses the process of preparing for a surgical mission with the local team, deciding between valve repair and replacement with patients and families, and the importance of maintaing close follow-up with patients. Drs Novick and Cardarelli describe the process for assembling the volunteer team and share the advice they give to first-time volunteers. In closing, they offer their thoughts on the biggest challenge facing humanitarian surgery efforts.
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  • Video
The pulmonary autograft operation was introduced by Donald Ross in 1967. Since then, the Ross operation has become a viable and durable option for aortic valve replacement in both the pediatric and adult populations (1). Pulmonary autograft dilatation is one of the complications noted in the adult population. Because of this, the Ross operation is showing a declining trend in this adult population. To prevent this complication, Ross Ungerleider came up with a simple and reproducible modification by adding a Dacron tube graft over the pulmonary autograft, and found no pulmonary autograft dilatation in 30 patients over the period of four years (2). The concerns raised with the modified Ross procedure are that the Dacron tube graft is a cylindrical graft and the sinus portion of the autograft is essential for the normal functioning of the leaflets, as studied in valve-sparing aortic root replacement procedures and experimental studies, and the modified Ross procedure does not address and prevent the potential threat to the valve leaflets function in the long term (3). The pseudosinus creation in the Dacron graft is very important to decrease the stress and strain on the leaflets, so that it is closer to normal, as studied by K .Jane Grande-Allen et al (3).Keeping this in mind, the author has made an additional modification to the modified Ross operation by removing the autograft sinuses, which were getting restricted by the cylindrical Dacron graft, and creating a pseudosinus/neosinus in the Dacron graft.With these modifications to the modified Ross operation, the author hopes to take care of the pulmonary autograft dilatation at all three levels:Annular level – The author sutures the autograft to the Dacron graft and then to the aortic annulus, which prevents annular dilatation.Sinuses – By excising the native autograft sinuses, which are being restricted by the Dacron graft, and creating the pseudosinus/neosinus in the Dacron graft, the author hopes to preserve the valve leaflet function.Sinotubular junction – Since the author is fixing the commissures to the Dacron graft and then suturing the Dacron graft to the ascending aorta, the dilatation at the sinotubular junction is nullified.ReferencesRoss DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;290(7523):956-958.Ungerleider RM, Ootaki Y, Shen I, Welke KF. Modified Ross procedure to prevent autograft dilation. Ann Thorac Surg. 2010;90(3):1035-1037.
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Mr Felice Granato demonstrates a thoracoscopic right upper lobectomy, which was performed for a primary pulmonary malignancy. The Harmonic HD was adopted for sealing of one of the segmental arteries (A2). It was also used to dissect the soft tissues, the pleura, the pulmonary parenchyma, and importantly, to perform an extensive and homeostatic lymphadenectomy. The video also demonstrates the key steps of the procedure, the segmental arterial branches of the right upper lobe, and their relationship with the surrounding structures. This anatomy is normally encountered during a right upper lobectomy and so the authors aim to provide a valuable didactic material.They conclude that the Harmonic HD can be safely adopted to reduce the cost of video-assisted thoracoscopic lobectomy through:Reduction of stapler application.Division of pulmonary artery vessels to a max diameter of 7 mm.Division of small portions of pulmonary parenchyma regardless the presence of surgical clips.Reduction of usage of disposable instruments (eg, l-hook, dissectors, bipolar diathermy).Safe blunt and sharp dissection of vascular and bronchial structures.Allows a safe, lymphostatic, quick, potentially more extensive, and minimally instrumented lymph node dissection.Suggested ReadingLandman J, Kerbl K, Rehman J, et al. Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model. J Urol. 2003;169(2):697-700.Liu CY, Lin CS, Shih CH, Liu CC. Single-port video-assisted thoracoscopic surgery for lung cancer. J Thorac Dis. 2014;6(1):14-21. Molnar TF, Benko I, Szanto Z, Laszlo T, Horvath OP. Lung biopsy using harmonic scalpel: a randomised single institute study. Eur J Cardiothorac Surg. 2005;28(4):604-606.
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The authors present a video showing their technique of totally endoscopic aortic valve replacement with a bovine pericardial valve (Trifecta GT, Abbott), performed for an 81-year-old patient with severe aortic stenosis and moderate aortic regurgitation. The patient was heavily symptomatic in class III and had a EuroSCORE II of 2.36. The patient was positioned supine on the operating table, with his right shoulder elevated by 30 degrees. Double lumen ventilation was also used. The operation was performed through a 3 cm working incision in the second intercostal space parasternally, with two 10 mm ports in the second and fifth intercostal spaces in the anterior axillary line. The extra small Alexis wound protector was used in the working incision. A 3D 30-degree Karl Storz endoscope was inserted in the second intercostal port and the whole of the procedure was done under stereoscopic vision. The fifth intercostal port was used for the right-hand instruments during the opening of the pericardium and for the left atrial vent while the aorta was cross-clamped.Three pericardial retraction sutures where used to retract the pericardium and the heart towards the endoscope (the sutures were externalized in the first, third, and seventh intercostal spaces in the middle axillary line).The Chitwood cross-clamp was inserted through a separate hole in the first intercostal space, anterior and superior to the endoscope. On femoro-femoral cardiopulmonary bypass, the aorta was cross-clamped and Custodiol cardioplegia was used to arrest the heart. Half of the dose was given in the aortic root and the other half directly in the coronary ostia (due to the aortic regurgitation), after performing a transverse aortotomy 3 cm above the right coronary ostium. The heavily calcified valve was excised using long-shafted instruments, and the annulus was sized. A 23 mm Trifecta GT (Abbott) bovine pericardial prosthesis was inserted using 2/0 Ethibond sutures secured with the COR-KNOT® automated suture-fastening device. In order to facilitate the placement of the annular sutures, the authors used a self-expanded iron net to increase the volume of the aortic root.The aortotomy was closed in two layers, the heart was de-aired, and the cross-clamp was removed. Postoperative transesophageal echocardiography confirmed a normally functioning prosthesis. The patient was extubated a couple of hours later and had an uneventful recovery.Additional ResourcesPitsis A, Tsotsolis N, Nikoloudakis N, et al. Totally endoscopic redo tricuspid valve repair. CTSNet. June 2019. doi: 10.25373/ctsnet.8199260.Pitsis A, Nikoloudakis N, Tsotsolis N, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet. March 2019. doi: 10.25373/ctsnet.7837853.Dr Antonios Pitsis serves as a Proctor for Abbott.
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  • Video
A subxiphoid pericardial window is generally indicated for management of symptomatic pericardial effusion. ImagingGenerally, the patient will have had some type of imaging study, most often an echocardiogram or a computed tomography scan of the chest. It is important to review these studies prior to surgery to get a sense of the size of the effusion and to determine whether the effusion is predominantly anterior or posterior.In the subxiphoid approach, the surgeon will be accessing the pericardium anteriorly, over the right ventricle.AnesthesiaThe procedure can be performed under general anesthesia or under local anesthesia with sedation, depending on the hemodynamic stability of the patient.If using general anesthesia in a relatively unstable patient, the patient should be prepped and draped prior to induction in case a sudden cardiovascular collapse requires urgent surgical intervention.ProcedureA small upper midline incision is made over the xiphoid process.The linea alba is incised, exposing the preperitoneal fat, but the peritoneal cavity is not entered.The xiphoid process is excised with Mayo scissors, a rongeur, or electrocautery.The lower sternum is retracted anteriorly with a Richardson retractor. This will expose the cardiophrenic fat pad and not necessarily the pericardium. Use a small sponge stick or Kittner blunt dissector to sweep the overlying fat pad until the glistening pericardium can be visualized.If the preoperative imaging study showed a good amount of fluid collection anteriorly, one can safely use a #15 blade to incise the pericardium. The author would not recommend using a #11 blade.With drainage, hemodynamic collapse can occur as a result of a diminished preload. It is important to communicate this with anesthesia ahead of time and to administer fluid boluses as necessary.Next, grab an edge of the incised pericardium with a tonsil and excise about an inch and a half of tissue to create the window.Use a Yankauer suction tube to probe the pericardial sac and suction out any loculated areas.Introduce a drain into the pericardial sac. The author’s preference is to use a 10 Fr flat JP drain and to direct it posteriorly.Finally, close the incision.
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  • Video
Filmed during the the 27th ASCTVS and 65th IACTVS Conference, Dr Om P. Yadava, CEO and Chief Cardiac Surgeon of the National Heart Institute in New Delhi, India, and Editor-in-Chief of the Indian Journal of Thoracic and Cardiovascular Surgery, discusses the Arterial Revascularization Therapy (ART) Trial with Professor David Taggart from the University of Oxford in the United Kingdom. Dr Taggart feels that the ART Trial has something for everyone (1). Those who want to do bilateral internal mammary artery (IMA) surgery have ”As Treated” analysis to support their philosophy, while those wanting to use only a single IMA can resort to ”Intention to Treat” (ITT) analysis data from the ART Trial. He acknowledges that the biggest problem with the ART Trial is that 40% of the patients had a treatment different from what was planned – 14% of the anticipated bilateral IMAs crossed over to the single IMA group, 4% of the anticipated single IMAs crossed over to the bilateral IMA group, and 22% of patients had an additional radial artery (RA) placed as the second arterial conduit in the single IMA group. Dr Taggart candidly admits that this is a major confounder for the ART Trial, and at the time that they were designing the trial, they did not know that the RA could have such a major impact on outcomes as compared to the saphenous vein. However, he feels confident that bilateral IMAs, if analyzed in earnest, would prove to be superior to the single IMA, as was shown when the data of the highest performing surgeon, who contributed 416 surgeries using bilateral IMAs with barely 1.2% crossover, was analyzed independently. In this cohort, even the ITT analysis shows a survival benefit of bilateral IMAs. Unfortunately, surgeon inexperience became a major factor in the ART Trial and, in certain cases, 100% of patients crossed over from bilateral IMA to single IMA.To a provocative question asking what might occur if the ART Trial was redesigned, Professor Taggart notes that all the lessons learned have been incorporated into the ROMA Trial being carried out by Mario Gaudino et al. Surgeons’ claims of being able to perform the bilateral IMA procedure is not sufficient, but actual performance and the proof thereof is mandatory. Professor Taggart further warrants that the ART Trial will be followed beyond ten years to see whether the survival curves diverge for ITT analysis. Contraindications to bilateral IMAs, according to the ART Trial, would be insulin-dependent diabetes mellitus, specifically in obese individuals, and chronic obstructive airways disease with some early shoots of higher complications in women and the elderly, which were thus relative contraindications.ReferenceTaggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees B, et al for the Arterial Revascularization Trial Investigators. Bilateral versus single internal thoracic artery grafts at 10 years. N Engl J Med. 2019;380:437-446.
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  • Video
The authors demonstrate a robot-assisted lung volume reduction surgery (LVRS), performed for a 71-year-old man who was an ex-smoker with severe chronic obstructive pulmonary disease (COPD) (FEV1, 0.68 L or 22%; DLCO, 51%; MRC Dyspnea scale, 4). Extensive preoperative investigation included high resolution computed tomography with StratX lung report, bronchoscopy with Chartis balloon pressure assessment, transesophageal echocardiography, right and left cardiac catheterization, and cardiac magnetic resonance imaging. Following discussion at a National COPD LVRS multidisciplinary meeting, the decision was made to proceed with surgery. After induction of general anesthesia, a double-lumen endotracheal tube was sited to facilitate single-lung ventilation. The patient was placed in the right lateral decubitus position. An ultrasound-guided interfascial serratus plane block was performed with long-acting local anesthetic prior to the procedure, providing good postoperative analgesia of the hemithorax.The da Vinci Xi robotic platform was used. This system facilitates CO2 insufflation (the less emphysematous lung with less air trapping tends to preferentially deflate first), 8 mm port hopping with a 30 degree tridimensional robotic camera, and closed robotic stapling of the lung parenchyma using a 12 mm port, with minimal disruption to the intercostal space and intercostal nerve. This limits acute and chronic pain and obviates the need for spinal epidural analgesia regimens. Three ports are used, two 8 mm and one anterior 12 mm port. The first port to be placed is the 8 mm camera port, inserted slightly anterior to the scapular tip. For the da Vinci Xi system, the distance between the ports should be 4 cm at a minimum. This facilitates optimal manipulation of the instruments within the chest cavity. The authors endeavor whenever possible to keep all three ports in the same intercostal space in order to limit postoperative pain.The first intraoperative step was a thorough evaluation of the entire lung, looking for any significant bullae or blebs. Given that the da Vinci system does not provide tactile feedback to the operator, it is vital that the surgeon’s instruments are always under view in the chest to minimize the risk of iatrogenic injury.The authors then proceeded to the perfusion assessment. The da Vinci Firefly system involves the injection of indocyanine green (ICG) tracer into the blood, which is then detected using near-infrared imaging. Dilute 1 ampoule (25 mg) of Verdye (ICG) with 10 ml water for injection to give a 2.5 mg/ml solution. Administer the ICG in a 3 ml bolus and repeat as necessary, to an upper limit of 0.3 mg/kg. ICG is confined to the vascular system, has a half-life of 3-4 minutes, and is eliminated by the liver (1). The system allows for real-time intraoperative assessment of pulmonary perfusion, with ICG detectable in the lung parenchyma within seconds following injection, thus guiding resection. In this patient, the lingua demonstrated comparatively good perfusion, and therefore the targeted resection avoided this area entirely.The final operative step was the resection. A significant advantage of the da Vinci Xi system is that it allows for robotic stapling using the EndoWrist 30 mm or 45 mm stapler, reducing tremor and improving dexterity due to fully wristed articulation and SmartClamp feedback. This stapler has the greatest side-to-side articulation currently available, with a range of 108 degrees total side-to-side and 54 degrees total up-and-down. This contributes greatly to the efficiency of the procedure, maintaining the contour of the lung in a limited operative field and minimizing the risk of postoperative air leak.ReferencesLue JR, Pyrzak A, Allen J. Improving accuracy of intraoperative diagnosis of endometriosis: role of firefly in minimal access robotic surgery. J Minim Access Surg. 2016;12(2):186-189.
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  • Video
Perclose ProGlide® suture mediated closure is a common technique for the percutaneous delivery of a suture for closing the common femoral artery access site at the conclusion of transcatheter interventions. This technique is considered a basic skill for performing transcatheter procedures, and it is one of the must-learn skills for graduating cardiac surgery residents. In this video, the authors demonstrate the Perclose® suture mediated closure technique for closure of the femoral artery after transcatheter aortic valve replacement, and they also show the device functions in an ex vivo setting.
Data Types:
  • Video