Repair of acute postinfarction atrioventricular dehiscence in a patient with posterior left ventricular aneurysm

Abstract

the brachial plexus and excluding neural foramina extension. There are several surgical approaches for thoracic outlet pathology. These include supraclavicular, transaxillary, and posterior thoracoplasty for first rib excision in thoracic outlet syndrome. For Pancoast tumors, an anterior (Dartevelle), posterior (Shaw-Paulson), and hemiclamshell or Masaoka approach have been described. The Masaoka approach involves a transverse cervical collar incision and proximal median sternotomy extended to the third or fourth anterior intercostal space. We used this approach, and it provided excellent exposure. We resected the first rib subperiosteally from inside the chest, as described by Nomori and colleagues. This improves exposure by facilitating lateral retraction of the anterior chest wall flap and avoids the need to divide or resect the medial third of the clavicle, which can lead to postoperative shoulder girdle dysfunction. Vanakesa and Goldstraw reported that the anterosuperior approach provides excellent exposure for tumors at the base of the neck. It was associated with low morbidity, a short postoperative stay, and adequate exposure for subclavian vessel resection or reconstruction. CONCLUSIONS We present the resection of a large bilobed thoracic outlet mass. We recommend an anterior hemiclamshell surgical approach because it provides excellent exposure for tumor removal, first rib resection, and vascular reconstruction. Bipolar electrocautery is essential to avoid any iatrogenic neuropraxias when dissecting the brachial plexus or should any bleeding be encountered around the neural foramina. Monitored somatosensory evoked potentials and free running electromyelogram similarly decrease the risk of neurologic injury.