Introduction

Abstract

After many years of “standard” aortic valve replacement, surgeons are revisiting other approaches, including aortic valve repair (including valve-sparing techniques), different prostheses, and apical–aortic conduits. Dr. Sundt has arranged for two groups with significant experience with apical–aortic conduits to present the “off-pump” and “on-pump” approaches. Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collaterals is a daunting lesion for even the most experienced congenital heart surgeon. Dr. Bradley has put together alternative approaches to this difficult lesion from two highly experienced groups. Lung volume reduction surgery is gradually developing a place in the thoracic surgeons’ armamentarium. Outcomes remain highly dependent on patient selection and technical aspects of the procedure. Dr. Jones has developed a description of very different approaches—median sternotomy in one case and a thoracoscopic approach in the other. We hope our readers will enjoy the descriptions of alternate approaches to these three problems. Recent progress in the development of percutaneous aortic valve prostheses has refocused surgeons’ attention to alternative techniques for relief of aortic valvular stenosis. The use of apical–aortic conduits was introduced in 1965 by Bernhard and was rapidly adopted by surgeons interested in congenital heart disease for the management of complex aortic valve and ascending aortic pathologies. Dr. John Brown has been a pioneer in this area, having published numerous articles on the use of apical–aortic conduits over the past 30 years. He has developed an approach for conducting the procedure without the use of cardiopulmonary bypass, which is most intriguing and may be of particular value in elderly patients with extensive peripheral atherosclerotic disease as well as in the pediatric population in which Dr. Brown’s principal experience resides. Dr. Kenton Zehr has also published the Mayo Clinic experience with apical–aortic conduits, principally in the adult population. Dr. Zehr has emphasized the value of apical–aortic conduits for acquired aortic stenosis in patients with a hostile mediastinum due either to multiple coronary grafts or to severely calcified ascending aorta. As such, it may be a competing technology for percutaneous valve procedures. We believe the readers will enjoy comparing and contrasting these two approaches to the construction of the apical–aortic conduit and hope that they will find value from them in their clinical practice. Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries is one of the most complex lesions confronting congenital heart surgeons. The goal of surgical therapy is to create separate pulmonary and systemic circulations with the lowest possible right ventricular pressure. The variability of the central and collateral pulmonary circulation mandates flexibility in approach, which may include single-stage repair or staged unifocalizations in appropriate patients. Further challenges include the decision of whether to close the ventricular septal defect, the effective coordination between surgeons and interventional cardiologists, and the use of newer imaging modalities, such as computed tomography angiography. Dr. Lofland from Kansas City illustrates his decision algorithm and approach to single-stage unifocalization via a median sternotomy. For comparison, Dr. Kurosawa from Tokyo presents a case series of staged unifocalizations through thoracotomies including innovative approaches such as the use of the azygos vein as a conduit. Few operations in general thoracic surgery have generated as much controversy as lung volume reduction surgery (LVRS). Although LVRS was initially reported in 1959 by Brantigan and colleagues, Joel Cooper and colleagues at Washington University subsequently re-introduced it with their seminal report in 1996. Much of the controversy regarding the operation has dealt with patient selection criteria, comparisons to best medical care in the National Emphysema Treatment Trial, and cost–benefit analyses. Additionally, most thoracic surgeons who have performed a significant number of these procedures realize that the conduct of this operation is usually rather straightforward. There are, however, important and sparingly described technical considerations for the majority of thoracic surgeons who have limited experience with this operation. In this issue, Dr. Joel Cooper describes his approach for a LVRS through a median sternotomy, whereas Dr. Robert McKenna, one of the pioneers in thoracoscopic surgery, describes his approach for thoracoscopic LVRS. Not withstanding the choice of the incision, the similarity of both approaches is obvious with the adherence to the operative principles necessary for a successful outcome described by both authors. Given that this operation will be performed for many years to come, these two technical reports will most certainly be read and reviewed by both current and future thoracic surgeons interested in the surgical treatment of end-stage lung disease.