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The Coronaries
Published in Theo Kofidis, Minimally Invasive Cardiac Surgery, 2021
László Göbölös, Johannes Bonatti
With the constant development of surgical techniques and improving software and hardware support, a further broad application spectrum of robotic-facilitated CAB is likely. Special demand for surgeon and team training in the field will probably focus these procedures in specific centers. Simulation sessions are undoubtedly key components of surgical team education. Complex procedures are already performed on a regular basis, and a significant proportion of standard operations via sternotomy is expected to be replaced step by step by minimally invasive robotic procedures in the near future. Hybrid methods are increasingly incorporated into the robotic armamentarium, and recent developments of procedure-specific robotic instruments will optimize exposure of the cardiac back wall (Figure 12.2.36). Single-port access is under further expansion in endoscopic surgical fields, and will soon offer new prospect in TECAB techniques. Automatic anastomotic devices offer another novel future pathway, although further clinical tests have to commence to warrant safe daily application [39].
Thymectomy
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
A sternotomy is a relatively standard and straightforward approach. The patient is in the supine position with the arms at the side. The incision runs in the midline from the sternal notch to the xiphoid. The sternum is split using an oscillating sternal saw and exposure of the thymus is obtained by use of a sternal retractor (Figure 23.2a). The dissection is relatively easy and can begin with either the lower or upper horns. The thymus is relatively easily dissected off the pericardium and great vessels. Care must be taken to protect the phrenic nerve, which runs along the lateral border of the thymus, down the pericardium. Care should also be taken to avoid entering the pleural cavity if possible.
Repair of Extensive Aortic Aneurysms: A Single-Center Experience Using the Elephant Trunk Technique over 20 Years
Published in Juan Carlos Jimenez, Samuel Eric Wilson, 50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know, 2020
Juan Carlos Jimenez, Samuel Eric Wilson
In 1983, Hans Borst1 and colleagues described the “elephant trunk” technique. This is a staged procedure in which the ascending aorta and aortic arch are repaired through a sternotomy and a portion of aortic graft is left extending unanchored into the proximal descending aorta, to be retrieved via a subsequent thoracotomy/thoracoabdominal incision and sutured end-to-end to a second graft used to repair the remaining distal aortic segment. The staged nature of this procedure allows for a period of recovery between the operative encounters that reduces the burden on the patient and improves the tractability of the procedure for the care team. When feasible, performing the sternotomy first can result in a shorter time interval between the proximal and distal operations, since recovery time following sternotomy is generally shorter and less painful than recovery for thoracotomy. A downside of staging the procedure—especially for large-diameter aneurysms or those in high-risk patients, such as those with Marfan syndrome—is that risk of rupture in the untreated segment remains until the entirety of the disease has been addressed.
Epicardial transplantation of autologous atrial appendage micrografts: evaluation of safety and feasibility in pigs after coronary artery occlusion
Published in Scandinavian Cardiovascular Journal, 2022
Annu Nummi, Tommi Pätilä, Severi Mulari, Milla Lampinen, Tuomo Nieminen, Mikko I. Mäyränpää, Antti Vento, Ari Harjula, Esko Kankuri
A standard anterior sternotomy was performed under anesthesia. Before any cardiac interventions, echocardiography (echo) was carried out to assess baseline cardiac function. Then the right atrial appendage (RAA) was ligated using a purse string suture. The RAA was removed from all animals in both groups. The standardized size of the RAA tissue used for AAMs patch was 10 mm × 5 mm. For the animals in the AAMs patch group, the harvested RAA was processed mechanically on-site in the operating room using a tissue homogenizer (Rigenera-system, HBW s.r.l., Turin, Italy) [25]. This system utilizes a sterile, single-use tissue mechanical homogenizer surface to generate the micrografts and yields ∼ 5–10 millions of viable cells per gram of RAA tissue [25]. The isolated AAMs were applied in standard cardioplegia suspension, and to seal the micrografts and the suspension to the patch fibrin sealant (TisseelTM, Baxter Healthcare Corp. Westlake Village, CA, USA) was added into the suspension. We used an ECM sheet (Cormatrix® ECMTM Technology, Cormatrix Cardiovascular Inc., Atlanta, GA, USA) as the patch material. The AAMs suspension was placed onto the sheet and the patch was ready to be placed with the AAMs facing the epimyocardium.
Less invasive aortic valve replacement using the trifecta bioprosthesis
Published in Scandinavian Cardiovascular Journal, 2022
Alfonso Agnino, Ascanio Graniero, Piersilvio Gerometta, Laura Giroletti, Giovanni Albano, Claudio Roscitano, Amedeo Anselmi
In the study population, the intended operative procedure could be performed in all cases, without instances of conversion to full sternotomy. During the study period, there were no cases of intraoperative decision to implant another bioprosthesis in a case where the use of a Trifecta GT had been foreseen. Average CPB and aortic clamp times were 102 ± 19 min and 77 ± 17 min, respectively. The distribution of the sizes of the implanted bioprostheses is as follows: 19 mm in 6%, 21 mm in 32%, 23 mm in 36%, 25 mm in 19%, 27 mm in 7%. There was a total of 36 associated procedures, including 17 cases of supracoronary ascending aortic replacement (13%), 18 cases of septal myectomy (13%), and 1 instance of coronary revascularization (1%) (left internal thoracic artery-to-left anterior descending artery bypass grafting). In no case a second CPB run was needed. Table 2 reports stratified intraoperative data according to the type of access to the aortic valve. Of note, no statistically meaningful differences in terms of CPB and aortic clamp time were identified among groups. No statistical difference was identified in terms of mechanical ventilation time and ICU stay. In the interpretation of such results, the rate of concomitant procedures in the UMS and RMS subgroups need to be considered, while AVR was an isolated procedure in all RAMT cases.
Combined liver transplantation and off-pump coronary artery bypass grafting: a report of two cases
Published in Acta Chirurgica Belgica, 2022
Tumay Uludag Yanaral, Gokhan Ertugrul, Mustafa Ozer Ulukan, Pelin Karaaslan, Ibrahim Oguz Karaca, Murat Dayangac
Cardiac surgery started with median sternotomy. The pericardium was then opened, and the greater saphenous vein was simultaneously harvested using a traditional long incision. CABG was performed on the beating heart. LAD and the circumflex artery in the first patient, and LAD and the second obtuse marginal artery in the second patient were grafted using saphenous vein graft segments with standard techniques. The reason for using saphenous vein grafts instead of internal mammary artery grafts was the occlusion of the subclavian artery in the first patient and the low-flow internal mammary artery in the second patient. Proximal anastomoses were performed on the appropriate regions of the ascending aorta using a Castaneda clamp. Heparin was neutralized with protamine at the end of OPCAB. The sternotomy incisions were left open in order to prevent shear stress to the sternum and take advantage of a larger surgical field during LT.