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  • The patient is an 80-year-old woman with severe mitral valve regurgitation and moderate-severe mitral valve stenosis who was evaluated for mitral valve replacement. The patient had a mitraclip procedure performed two years prior and her mitral regurgitation had recurred. Her symptoms included fatigue and dyspnea on exertion. She had prior coronary stents and her imaging studies demonstrated heavy mitral annular calcification (MAC), more prominent posteriorly and at the commissures. Given her age, severe MAC, and the small annular sizel, the patient was felt to not be a good candidate for an operation for the resection of the calcium bar, so an alternative approach was seeked. After counseling the patient on an off-label balloon expandable transcatheter aortic valve in MAC, and after obtaining prior authorization and institutional approval for the procedure, the patient consented to this approach. The patient was offered a right minithoracotomy mitral valve operation. The operation was successful, with a 130 minute crossclamp. Twenty minutes of this time was spent constructing the composite TAVR valve felt/bovine pericardial composite on the back table. The patient was extubated six hours after arrival to the intensive care unit and had a 2-day stay in intensive care. She had an uneventful recovery and was discharged on postoperative day seven. Her echocardiogram prior to discharge showed no residual mitral regurgitation and mean gradient of 2 mm Hg across the valve. DiscussionMitral valve replacement in severe mitral annular calcification represents a risky endeavor. The concern for AV-groove disruption is ever present. Removal of the calcium bar with patch reinforcement of the posterior annulus is not a simple technique. This technique carries a palpable risk for life-threatening complication, even with the most experienced surgeons. Newer techniques have been proposed to address severe MAC, and in six years, the use of a transcatheter aortic valve in the mitral position with different modifications has gain traction (1, 2, 3). The operation has been performed via sternotomy (4) and via a minimally invasive approach (1). Different modifications to the transcatheter balloon expandable valve have been described, but perhaps the most consistent is the suturing of the felt strip on the atrial side of the valve accompanied by a pericardial doughnut shaped washer. The rationale behind these two modifications is to minimize the risk for paravalvular leak and prevent valve migration.A word of caution is warranted when performing this operation, and it is to factor in the time that it takes to construct the modifications on the back table. Sizing the valve using a balloon early on after resecting the anterior leaflet allows a second surgeon to perform the modification while the primary surgeon applies the annular sutures.Direct implantation of a transcatheter aortic valve of a balloon expandable type in severe mitral annular calcification is safe and effective. It can be performed via sternotomy and minimally invasive approaches, such as right minithoracotomy. Learn more: https://www.ctsnet.org/article/minimally-invasive-direct-transcatheter-aortic-valve-replacement-mitral-annular
    Data Types:
    • Video
  • Small aortic root enlargement using the modified Manouguian technique for mechanical valve implantation is challenging, especially in the presence of calcified aortic annuli (1, 2). In order to augment the benefits of the modified Manouguian technique, the authors used a pericardial patch and performed a modification in the aortotomy incision - without entering into the left atrium or incising the anterior leaflet of the mitral valve. The small aortic root is then enlarged by using a tear drop shaped glutaraldehyde-treated pericardial patch into the subaortic curtain and the ascending aorta. Authors strongly recommend that the modified Manouguian technique using a pericardial patch aortoplasty is safe and feasible for patients who have a special consideration of patient-prosthesis mismatch, bioprosthesis, and short cross-clamp times. Important Steps 1. A standard median sternotomy was performed, and cardiopulmonary bypass (CPB) was established, with standard ascending aorta cannulation and right atrial cannulation using a two-stage single venous cannula. 2. Venting from the left heart was performed through the right superior pulmonary vein. 3. The cross-clamp was applied to the ascending aorta and an oblique aortotomy was performed. Aortotomy was extended into the fibrous tissue between the noncoronary cusp and the left coronary cusp and onto the subaortic curtain. 4. The aortic valve was exposed and cold blood antegrade cardioplegia was given. However, the exposed aortic valve was excised and the annulus was measured carefully according to the patient's body surface area. 5. A modified Manouguian technique was performed without incising to anterior mitral leaflet or extending incision into the left atrium (2, 3). 6. The aortic root enlargement was performed using a tear drop-shaped, glutaraldehyde-treated pericardial patch. This pericardial patch aortoplasty was performed using a 5.0 polypropylene continuous suturing technique, starting at the rock bottom of the aortic incision and continuing up to 2.5 cm above the aortic annulus. 7. Then the aortic annulus was resized, and a 21 mm size mechanical valve used to replace the native aortic valve (preoperative Echo findings of aortic annulus was 16 mm). 8. 2.0 pledgeted polyester sutures were installed circumferentially around the aortic annulus, and suturing was completed from the outside into the patch area. The suturing of the prosthetic valve was done and then fixed into place. 9. The aortotomy incision was then closed with a 4.0 polypropylene suture in a continuous fashion using the pericardial patch. 10. After weaning from CPB, protamine was administered and the procedure was completed in a standard fashion. Weaning from CPB was uneventful. 11. The postoperative period was uneventful and she is now doing well. References 1. Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg 1979;78(3):402–12. 2. Borowski A, Kurt M. A modification to the Manouguian aortoplasty for biological valve implantation in patients with small (< or =19 mm) aortic anuli--rationale and benefit. Tex Heart Inst J. 2008;35(4):425–427. 3. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92(8): 1022–29.
    Data Types:
    • Video
  • An 11-month-old boy presented with features of congestive cardiac failure. On clinical examination, the lower limb pulses were feeble when compared to the upper limb pulses. The baby was investigated for coarctation of aorta. Echocardiography made the diagnosis of coarctation of aorta, with severe pulmonary arterial hypertension. The patient also had a small atrial septal defect with left to right shunt. Computed tomography (CT) angiogram was performed to delineate the exact anatomy. The baby was initially stabilized and planned for early coarctation repair. In view of poor collaterals and severe pulmonary arterial hypertension, it was decided to proceed with coarctation resection and end-to-end anastomosis after placing an arch of aorta to the descending thoracic aorta bypass circuit. This bypass circuit prevents the spinal cord ischemia. In this bypass circuit, a pump was not used.As described in the video, the patient was positioned in the right lateral position after induction with general anaesthesia. A femoral line and a radial arterial line were inserted before positioning to monitor the pressure difference across the coarctation and also to measure the adequacy of repair. Posterolateral thoracotomy was performed. The chest was entered via the fourth intercostal space. The lung was retracted medially, and the mediastinal pleura over the aorta was dissected. The distal arch and proximal descending thoracic aorta (DTA) was mobilized. The left subclavian artery, DTA, and arch of aorta were looped. During dissection, patent ductus arteriosus was present. It was not functional. It was doubly ligated and divided, to aid in mobilization of the aorta.The next step was cannulation of the arch of aorta and DTA to establish the bypass circuit, after systemic heparinization. Once the arch to DTA bypass was established, the distal perfusion pressure improved to that of the precoarctation pressure. Then the aorta was clamped proximal and distal to the coarctation segment in such a way that the proximal clamp was placed distal to the arch cannulation site, and the distal clamp was placed proximal to the DTA cannulation site. The coarctation segment was resected till the normal portion of the aorta. In this case, the coarctation of the aorta was juxta ductal. After resection, end-to-end anastomosis was performed. Aortic clamps were removed and hemostasis was checked. The bypass circuit was clamped to check the pressure difference between the radial and femoral arterial lines. It was almost equal; this showed the adequacy of repair. Protamine was started and aortic cannulae were removed. Mediastinal pleura was closed over the aorta. The chest was closed in a routine way after placing an intercostal drainage tube.The patient did well in the postoperative period and is doing well in follow-up.ReferenceChristenson JT, Sierra J, Didier D, Beghetti M, Kalangos A. Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral circulation. Cardiol Young. 2004 Feb;14(1):39-45.
    Data Types:
    • Video
  • This case report suggests that recurrent right pleural effusions could be a side effect of hepatic artery infusion pump chemotherapy in the treatment of metastatic colorectal cancer. Learn more:
    Data Types:
    • Video
  • Thoracic outlet syndrome is a pathology caused by compression of the subclavian artery, subclavian vein, and/or brachial plexus. Its most effective treatment is the section of the scalene muscles, along with the removal of the first rib and section of adjacent ligaments. The authors show the first rib resection technique by videothoracoscopy. A 35-year-old woman comes to the thoracic surgery department due to pain in the upper left limb, associated with paresthesia in the shoulder and forearm, which increases with abduction. She presents a Doppler ultrasound of both upper limbs, where there is evidence of compression of the left subclavian artery, with the arm abducted at the level of the thoracic outlet.The authors describe the technique by videothoracoscopy through two ports: one of 10 mm for the video camera and another of 2 cm as a working port. The authors use this technique regularly with very good results. The videothoracoscopic or VATS approach to thoracic outlet syndrome provides, unlike classical approaches, an excellent visualization of all bone, vascular, and nervous structures in the area. It allows for the identification of the first rib in its entirety just by opening the parietal pleura. It also allows for the removal of the first rib in its entirety from the chondrocostal junction in the anterior area until its disintegration of the costovertebral joint. It also facilitates the section of the anterior and middle scalene muscle with perfect visualization of the artery, vein, and brachial plexus, making it safer, as well as improving control and preventing lesions on the sympathetic chain and the stellate ganglion. The authors add better management of postoperative pain and shorter hospital stay.
    Data Types:
    • Video
  • Betsy Evans of Leeds General Infirmary in the United Kingdom presents a discussion on TAVI and surgery for prosthetic valve failure. She discusses the background of biological valve implant rate, rate of TAVI, and structural valve deterioration and treatment options. She focuses on two treatment techniques: redo AVR surgery and the TAVI valve-in-valve procedure. This presentation was originally given during the SCTS Ionescu University program at the 2019 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.
    Data Types:
    • Video
  • This is the case of an elderly woman with significant tracheobronchomalacia (TBM) who presented with exertional dyspnea and cough. The patient underwent awake fiberoptic bronchoscopy, which confirmed posterior malaria with >90% narrowing of the trachea and right mainstream bronchus. The patient was treated conservatively with bronchodilators for six months without symptomatic improvement. She was referred for tracheobronchoplasty via a minimally invasive approach. A four-arm robotic-assisted approach was selected. The trachea was dissected to the level of the thoracic inlet and the carina skeletonized. The left mainstem bronchus was mobilized, allowing exposure of the entire membranous trachea. The tracheoplasty was performed using four columns of interrupted horizontal mattress 4-0 vicryl sutures to a proline mesh. The bronchoplasty was performed using three columns of sutures. Frequent intraoperative bronchoscopy was performed.While tracheobronchoplasty for TBM has traditionally been performed via an open approach, the robotic surgical platform has offered a minimally invasive option for performing the often complex technical maneuvers required in this procedure. Early results of minimally invasive tracheobronchoplasty have been promising (1).ReferenceLazzaro R, Patton B, Lee P, Karp J, Mihelis E, Vatsia S, et al. First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia. J Thorac Cardiovasc Surg. 2019 Feb;157(2):791-800.
    Data Types:
    • Video
  • Bronchopulmonary sequestration is a rare disorder affecting 0.15 to 6.4 percent of all congenital pulmonary malformations. Treatment via embolization or surgery has been previously described. The authors report an intralobar pulmonary sequestration in an adult patient that was successfully treated with a hybrid approach of transarterial embolization followed by thoracoscopic segmentectomy. The patient was a 31-year-old woman with prior episodes of asthma exacerbation who was diagnosed incidentally with an intralobar pulmonary sequestration of the posterior basal left lower lobe. CT scan demonstrated an arterial feeding vessel to the sequestration originating from the celiac artery of the abdominal aorta. Surgical resection was recommended. Given the size, origin, and location of the feeding vessel to the sequestration, the authors elected to coil embolize the feeding artery prior to surgery to facilitate a safe thoracoscopic approach. The patient underwent thoracoscopic left lung basilar segmentectomy the next day. The large aberrant vessel was identified, dissected, and divided using a tan stapler at the level of the first bifurcation. The basilar arteries were subsequently divided with an endoscopic stapler, and the superior segmental artery was spared. The basilar segmental bronchus and inferior pulmonary vein distally to the branch feeding the superior segmental vein were isolated and divided, individually. The basilar segment was then separated with parenchymal stapling. The specimen was placed in a lobectomy bag and extracted through the wound. Intercostal nerve blocks were provided with liposomal bupivacaine. The patient tolerated the procedure well. The patient was discharged on postoperative day two and seen for follow-up at four weeks with no complications.Bronchopulmonary sequestration is a rare disorder and identification of the aberrant systemic vessel is critical. A hybrid approach including preoperative transarterial embolization allows for a safe intraoperative dissection, prevents intraabdominal catastrophic bleeding, and has minimal morbidity.
    Data Types:
    • Video
  • The patient is an 80-year-old woman with severe mitral valve regurgitation and moderate-severe mitral valve stenosis who was evaluated for mitral valve replacement. The patient had a mitraclip procedure performed two years prior and her mitral regurgitation had recurred. Her symptoms included fatigue and dyspnea on exertion. She had prior coronary stents and her imaging studies demonstrated heavy mitral annular calcification (MAC), more prominent posteriorly and at the commissures. Given her age, severe MAC, and the small annular sizel, the patient was felt to not be a good candidate for an operation for the resection of the calcium bar, so an alternative approach was seeked. After counseling the patient on an off-label balloon expandable transcatheter aortic valve in MAC, and after obtaining prior authorization and institutional approval for the procedure, the patient consented to this approach. The patient was offered a right minithoracotomy mitral valve operation. The operation was successful, with a 130 minute crossclamp. Twenty minutes of this time was spent constructing the composite TAVR valve felt/bovine pericardial composite on the back table. The patient was extubated six hours after arrival to the intensive care unit and had a 2-day stay in intensive care. She had an uneventful recovery and was discharged on postoperative day seven. Her echocardiogram prior to discharge showed no residual mitral regurgitation and mean gradient of 2 mm Hg across the valve. DiscussionMitral valve replacement in severe mitral annular calcification represents a risky endeavor. The concern for AV-groove disruption is ever present. Removal of the calcium bar with patch reinforcement of the posterior annulus is not a simple technique. This technique carries a palpable risk for life-threatening complication, even with the most experienced surgeons. Newer techniques have been proposed to address severe MAC, and in six years, the use of a transcatheter aortic valve in the mitral position with different modifications has gain traction (1, 2, 3). The operation has been performed via sternotomy (4) and via a minimally invasive approach (1). Different modifications to the transcatheter balloon expandable valve have been described, but perhaps the most consistent is the suturing of the felt strip on the atrial side of the valve accompanied by a pericardial doughnut shaped washer. The rationale behind these two modifications is to minimize the risk for paravalvular leak and prevent valve migration.A word of caution is warranted when performing this operation, and it is to factor in the time that it takes to construct the modifications on the back table. Sizing the valve using a balloon early on after resecting the anterior leaflet allows a second surgeon to perform the modification while the primary surgeon applies the annular sutures.Direct implantation of a transcatheter aortic valve of a balloon expandable type in severe mitral annular calcification is safe and effective. It can be performed via sternotomy and minimally invasive approaches, such as right minithoracotomy. Learn more: https://www.ctsnet.org/article/minimally-invasive-direct-transcatheter-aortic-valve-replacement-mitral-annular
    Data Types:
    • Video
  • An 11-month-old boy presented with features of congestive cardiac failure. On clinical examination, the lower limb pulses were feeble when compared to the upper limb pulses. The baby was investigated for coarctation of aorta. Echocardiography made the diagnosis of coarctation of aorta, with severe pulmonary arterial hypertension. The patient also had a small atrial septal defect with left to right shunt. Computed tomography (CT) angiogram was performed to delineate the exact anatomy. The baby was initially stabilized and planned for early coarctation repair. In view of poor collaterals and severe pulmonary arterial hypertension, it was decided to proceed with coarctation resection and end-to-end anastomosis after placing an arch of aorta to the descending thoracic aorta bypass circuit. This bypass circuit prevents the spinal cord ischemia. In this bypass circuit, a pump was not used.As described in the video, the patient was positioned in the right lateral position after induction with general anaesthesia. A femoral line and a radial arterial line were inserted before positioning to monitor the pressure difference across the coarctation and also to measure the adequacy of repair. Posterolateral thoracotomy was performed. The chest was entered via the fourth intercostal space. The lung was retracted medially, and the mediastinal pleura over the aorta was dissected. The distal arch and proximal descending thoracic aorta (DTA) was mobilized. The left subclavian artery, DTA, and arch of aorta were looped. During dissection, patent ductus arteriosus was present. It was not functional. It was doubly ligated and divided, to aid in mobilization of the aorta.The next step was cannulation of the arch of aorta and DTA to establish the bypass circuit, after systemic heparinization. Once the arch to DTA bypass was established, the distal perfusion pressure improved to that of the precoarctation pressure. Then the aorta was clamped proximal and distal to the coarctation segment in such a way that the proximal clamp was placed distal to the arch cannulation site, and the distal clamp was placed proximal to the DTA cannulation site. The coarctation segment was resected till the normal portion of the aorta. In this case, the coarctation of the aorta was juxta ductal. After resection, end-to-end anastomosis was performed. Aortic clamps were removed and hemostasis was checked. The bypass circuit was clamped to check the pressure difference between the radial and femoral arterial lines. It was almost equal; this showed the adequacy of repair. Protamine was started and aortic cannulae were removed. Mediastinal pleura was closed over the aorta. The chest was closed in a routine way after placing an intercostal drainage tube.The patient did well in the postoperative period and is doing well in follow-up.ReferenceChristenson JT, Sierra J, Didier D, Beghetti M, Kalangos A. Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral circulation. Cardiol Young. 2004 Feb;14(1):39-45.
    Data Types:
    • Video