Left Anterior Thoracotomy Research Articles

The use of cardiopulmonary bypass in the extraction of intracardiac foreign bodies

Background: Intracardiac foreign bodies (FBs) are uncommon and have diverse presentations. The objectives of this study were to assess the types and presentation of intracardiac FBs and to evaluate the use of cardiopulmonary bypass (CPB) in their extraction. 
 Methods: A retrospective descriptive study was carried out on 12 patients with a history or radiological evidence of a foreign body in the heart or the great vessels who were admitted between 2013 and 2018. Sternotomy was performed in 8 patients and left anterior thoracotomy in 4 patients. CPB was used in 4 patients with cardioplegic cardiac arrest. Aorto-bicaval cannulation was performed in 3 patients and femero-femoral bypass in 1 patient.
 Results: The mean age of our patients was 32.7 ±21.7 years (range 2-62 years), six were males. Six different intracardiac FBs were reported including retained bullets (n= 3), migrated catheter piece (n=3), sewing needles (n=3), displaced pacemaker lead (n= 1), circular saw (n=1) and missed pigtail catheter after pericardiocentesis (n=1). Recovery from cardiopulmonary bypass was smooth, and no hospital complications were reported. The mean duration of postoperative mechanical ventilation in all sternotomy patients was 7.8 ± 6.7 hours (5 ±2.1 in CPB patients and 10.7±8.9 in non- CPB). The duration of hospital stay in CPB cases vs. non-CPB was (5.5±1.3 vs. 5.7±0.9 days). No postoperative wound infection nor sternal dehiscence were reported. One baby who had lateral thoracotomy died on the fifth postoperative day because of severe gastroenteritis. No residual pericardial or pleural collection were reported in 6 months follow-up period.
 Conclusions: Retrieval of intracardiac FBs can be performed safely with low morbidity and mortality. The use of CPB did not increase morbidity or mortality. Removal of all types of intracardiac FBs is recommended to avoid complications

ІННОВАЦІЙНИЙ ПІДХІД – МІНІІНВАЗИВНЕ БАГАТОСУДИННЕ КОРОНАРНЕ ШУНТУВАННЯ В УМОВАХ ПЕРЕДНЬОЇ ТОРАКОТОМІЇ

Personal experience with minimally invasive multivessel coronary grafting through left anterior thoracotomy is described. Currently, we use this technique routinely, regardless of the number of grafts, quality, and location of coronary targets, left ventricular ejection fraction, age, gender, body mass index. Our aim was to develop minimally invasive coronary artery bypass grafting technique, which would be equally effective and safe as compared to the conventional coronary grafting technique; would be reproducible and be applied for every patient with isolated coronary artery disease. 220 patients were operated and then analyzed. In all patients, complete revascularization was performed. Mean number of grafts was 3.37± 0.68 per patient (range 2-5). Left internal mammary artery was used in 206 patients, right internal mammary artery - in 4 patients, radial artery - in 37 patients, vein grafts - in 193 patients. Complete arterial revascularization was performed in 29 patients. We had no mortality. Mean aortic cross-clamp time was 70.7 ± 18.7 min (range 31 - 146 min). Mean cardiopulmonary bypass time was 137.5 ± 31.9 min (range 71 - 339 min). Postoperatively, total drainage in the first 12 hours was 376.7 ± 205.4 ml, ventilation time was 2.6 ± 1.4 hours, ICU stay was 2.3 ± 1.2 days. Conclusion. Minimally invasive coronary bypass grafting is an effective and safe surgical method. Complete revascularization could be performed regardless of the number of grafts, left ventricle ejection fraction, quality and size of coronary vessels, or age of the patient.

Complete Coronary Revascularization via Left Anterior Thoracotomy.

Our aim was to develop the minimally invasive coronary artery bypass grafting (CABG) technique, which is equally effective and safe compared with conventional coronary grafting technique, is reproducible, and can be applied in the vast majority of patients with isolated coronary artery disease. From July 2017 to November 2018 a total of 170 nonselected consecutive patients underwent minimally invasive on-pump multivessel CABG through the left anterior minithoracotomy in the fourth intercostal space using a Chitwood clamp and blood cardioplegia. We named this technique total coronary revascularization via left anterior thoracotomy. The mean number of grafts was 3.1 ± 0.7. Left internal mammary artery was used in 159 (93.5%) patients, right internal mammary artery in 4 (2.4%) patients, radial artery in 25 (14.7%) patients, and veins in 148 (87%) patients. We had no mortality, no postoperative myocardial infarcts, and no conversion to sternotomy. There were 2 postoperative strokes without residual neurological deficit and 2 revisions for postoperative bleeding. The total operation time was 258.8 ± 43.9 minutes, cardiopulmonary bypass time 135.8 ± 26.6 minutes, and aortic cross-clamp time 71.2 ± 19.4 minutes. The mean intensive care stay was 2.1 ± 0.56 days and mean total hospital stay 6.3 ± 1.3 days. Complete coronary revascularization could be routinely performed using the above-mentioned technique. No patient selection, based on number of grafts, quality and location of coronary vessels, left ventricle function, age, gender, or body mass index, is required.

Implante experimental de una bomba de asistencia circulatoria de flujo continuo en posición valvular aórtica

IntroductionThe implanting of an axial flow pump in an aortic valve position could decrease certain complications in current pumps. It could permit an anterograde blood flow in the heart and the aorta. It could avoid the making of a bag, as well as avoiding the need for inlet and outlet cannulas, and could slow down the scar formation in the cardiac apex. ObjectiveTo study the technical feasibility of the implanting of an axial flow pump in an aortic valve position, as well as to assess the haemodynamic effects and its impact on cardiac structures. MethodsA Jarvik 2000® pump adapted for an intra-valvular implant in 7 pigs was inserted using left anterior thoracotomy and under extracorporeal circulation. The pump was fixed to the aortic ring using sutures. It assisted the subjects for an hour during an assessment was made of the haemodynamic behaviour and the cardiac structures with an epicardial echocardiogram. After euthanasia of the animal, the heart was removed for an examination of its cavities. ResultsAll the procedures were completed with the technique. With the vasoactive drugs and epicardial pacemaker support, the pump was capable of maintaining the haemodynamics of the individuals. The echocardiogram showed adequate filling of the left ventricle and good functioning of the mitral valve. The post-mortem examination showed that the coronary ostia were free and there had not been any clots in the cardiac cavities. ConclusionsIn this animal model, the implanting of an axial flow pump in an aortic valve position was possible. The pump was able to maintain the haemodynamics of the animal without significantly affecting the cardiac structures.

Minimally Invasive Exchange of the HeartMate 2 (HM2) Left Ventricular Assist Device (LVAD) to HeartWare Ventricular Assist Device (HVAD) or HeartMate 3 (HM3)

Purpose Exchange of the HM2 LVAD may be necessary for pump thrombosis, malfunction, or infection. We describe a novel minimally invasive technique for exchange of HM2 to the new generation intrapericardial pumps, HVAD or HM3, and present our clinical experience with this technique. Methods Retrospective data of patients who underwent exchange of HM2 to HVAD or HM3 since June 2014 were reviewed. Patient characteristics, operative outcomes, and post-operative complications were compiled. Kaplan-Meier methodology was used to analyze survival following pump exchange. Results The study included 13 patients. The average age was 60 years. Indications for exchange were recurrent thrombosis in a second HM2 (12) and infection (1). All cases were done on cardiopulmonary bypass (CPB) with femoral cannulation. Surgical approach was via a left subcostal incision and left anterior thoracotomy in all cases and additional sternotomy in one case. Outflow graft-to-graft anastomosis was done in the subcostal incision. The new device was inserted in the previous apical ventriculotomy after removal of the HM2 inflow cannula. Mean duration of support on the second HM2 pump was 656 days. The mean CPB and surgical times were 112 and 291 minutes, respectively. Mean ICU and hospital lengths of stay were 7 and 16 days, respectively. 30-day post-op survival was 92% with 1 death on day 24 from sepsis. There was 1 re-operation for post-op bleed, 2 wound infections, and 2 cases of right ventricular insufficiency. No neurological events or recurrent pump thrombosis were reported. Mean survival at 1, 2, and 3 years was 69%, 40%, and 40%, respectively. Conclusion Exchange of the HM2 to new generation intrapericardial pumps may be indicated in cases of recurrent pump thrombosis, inflow cannula malposition, or device infection. This can be accomplished by a minimally invasive approach with a low surgical mortality and excellent long-term outcomes.

Less Invasive HeartMate 3 Implantation is Safe and Reproducible with Excellent Outcomes

Purpose The purpose of this study was to analyze early outcomes, safety and reproducibility of the less invasive HeartMate 3 implantation technique. Methods Retrospective review of prospectively collected data was performed on 53 consecutive patients implanted with left ventricular assist devices between February and September 2018 at a single institution. Patients were excluded if they were enrolled in a study requiring full sternotomy (3 patients), were a pump exchange (5 patients) or were implanted with the HeartWare device (4 patients). Safety outcomes included return to the operating room and overall survival. Results A total of 41 patients were included in the study. Thirty-nine patients were implanted with the complete sternal-sparing technique while two had an upper hemi-sternotomy with small left anterior thoracotomy. Average age was 53.6±13.9 years, 76% were male and 41% were INTERMACS Profile 1. Twelve patients (29%) had a right ventricular stoke work index less than 400. Nine patients (22%) were implanted off VA ECMO and 10 patients (24%) had previous cardiac surgery. All patients that qualified for the procedure were implanted using a less invasive technique. No patients required conversion to full sternotomy. Two patients (5%) returned to the operating room for bleeding. Twenty patients (49%) received a perioperative packed red blood cell transfusion within 24 hours of surgery. Median blood loss in the first 24-hours was 1042 mL (IQR=768-1307 mL). 2 patients (5%) requiring RVAD support. Median intubation time was 16 hours (IQR=9-34 hours). Median intensive care unit and hospital length of stay were 4 days (IQR=2-6 days) and 15.5 days (IQR=12-23 days), respectively. Thirty-day survival was 39/41 (95%). Conclusion Less invasive HeartMate 3 implantation in our single center setting is safe and reproducible with excellent outcomes. Multicenter studies are required to further validate this technique.

Effects of pulmonary artery banding in doxorubicin-induced left ventricular cardiomyopathy

ObjectiveCentral pulmonary banding has been proposed as a novel alternative for the treatment of left ventricular dilated cardiomyopathy in children. We sought to investigate the effects of central pulmonary banding in an experimental model of doxorubicin-induced left ventricular dilated cardiomyopathy. MethodsFour-month-old sheep (n = 28) were treated with intermittent intracoronary injections of doxorubicin (0.75 mg/kg/dose) into the left main coronary artery. A total dose of up to 2.15 mg/kg of doxorubicin was administered until signs of left ventricular dilation with functional impairment occurred by transthoracic echocardiography evaluation. Animals that survived were treated with surgical central pulmonary banding through a left anterior thoracotomy or sham surgery. Transthoracic echocardiography and pressure-volume loop measurements were used to compare left ventricular function preoperatively and 3 months later. Macroscopic and microscopic histologic examinations followed after hearts were harvested. ResultsNine animals from the central pulmonary banding group and 8 animals from the sham group survived and were included in the final analysis. Both groups showed similar inflammation and fibrosis upon histologic examination consistent with the toxic myocardial effects of doxorubicin. There were no differences in the echocardiographic measurements before central pulmonary banding or sham operation. Baseline measurements before the central pulmonary banding/sham operation were considered as 100%. The central pulmonary banding group had better left ventricular ejection fraction (102.5% ± 21.6% vs 76.7% ± 11.7%, P = .01), with a tendency for smaller left ventricular end-diastolic (101.2% ± 7.4% vs 120.4% ± 10.8%, P = .18) and significantly smaller end-systolic (100.3% ± 12.9% vs 116.5 ± 9.6%, P = .02) diameter of the left ventricle in comparison with the sham animals at 3 months. The end-systolic volume (101.4% ± 31.6% vs 143.4% ± 28.6%, P = .02) was significantly lower in the central pulmonary banding group 3 months postoperatively. Fractional shortening in the long axis (118.5% ± 21.5% vs 85.2% ± 22.8%, P = .016) and short axis (122.5% ± 18% vs 80.9% ± 13.6%, P = .0005) revealed significantly higher values in the central pulmonary banding group. In the conductance catheter measurements, no significant differences were seen between the groups for the parameters of systolic and diastolic function. ConclusionsCentral pulmonary artery banding in the setting of experimental toxic left ventricular dilated cardiomyopathy improved left ventricular echocardiographic function and dimensions.

Red tides: Mass casualty and whole blood at sea.

The U.S. Navy's casualty-receiving ships provide remote damage control resuscitation platforms to treat injured combatants deployed afloat and ashore. We report a significant mass casualty incident aboard the USS Bataan, and the most warm fresh whole blood (WFWB) transfused at sea for traumatic hemorrhagic shock since the Vietnam War. Casualty-receiving ships have robust medical capabilities, including a frozen blood bank with packed red blood cells (pRBC) and fresh frozen plasma (FFP). The blood supply can be augmented with WFWB collected from a "walking blood bank." Following a helicopter crash, six patients were transported by MV-22 Osprey to the USS Bataan. Patient 1 had a pelvic fracture, was managed with a pelvic binder, and received 4 units of pRBC, 2 units of FFP, and 6 units of WFWB. Patient 2, with a comminuted tibia and fibula fracture, underwent lower extremity four-compartment fasciotomy, and received 4 units of WFWB. Patient 3 underwent several procedures, including left anterior thoracotomy, aortic cross-clamping, exploratory laparotomy, small bowel resection, and tracheostomy. He received 8 units of pRBC, 8 units of FFP, and 28 units of WFWB. Patients 4 and 5 had suspected spine injuries and were managed nonoperatively. Patient 6, with open tibia and fibula fractures, underwent lower extremity four-compartment fasciotomy with tibia external fixation and received 1 unit of WFWB. All patients survived aeromedical evacuation to a role 4 medical facility and subsequent transfer to local hospitals. Maritime military mass casualty incidents are challenging, but the U.S. Navy's casualty-receiving ships are ready to perform remote damage control resuscitation at sea. Activation of the ship's walking blood bank to transfuse WFWB is essential for hemostatic resuscitations afloat. Study type: case series, level V.

Minimally Invasive Left Ventricular Assist Device Implantation: Implementation Early in a Surgical Career.

Several centers have presented minimally invasive surgical approaches to centrifugal left ventricular assist device implantation. Although minimally invasive implantation has been successfully performed by experienced surgeons, at large implanting centers, it is unknown whether these techniques are widely adoptable. We evaluated the experience of a surgeon early in his career with conventional and minimally invasive approaches to device implantation. All consecutive left ventricular assist device implantations by a single surgeon in the first year of practice (2015-2016) were retrospectively reviewed. Patients were stratified by standard approach, conventional full sternotomy versus a minimally invasive approach, left anterior thoracotomy and upper hemisternotomy. Demographics, perioperative variables, and short-term outcomes were compared using Wilcoxon rank-sum test. Thirteen patients were identified: six performed via the standard approach and seven performed via the minimally invasive approach. Preoperative demographics were comparable in both groups. However, there was significantly more preoperative right ventricle dysfunction in the minimally invasive group (P = 0.01). Although operative time was significantly longer in the minimally invasive cohort, there was a trend toward decreased cardiopulmonary bypass time. Six-month survival in both groups was 100%. Compared with conventional sternotomy, minimally invasive ventricular assist device implantation, performed by a surgeon in his first year of practice, had similar perioperative outcomes and excellent survival. Based on these data, minimally invasive implantation may be a feasible strategy for device implantation even early in a surgeon's career.

Mid-Term Results of Minimally Invasive Direct Coronary Artery Bypass Grafting.

BackgroundMinimally invasive direct coronary artery bypass grafting (MIDCAB) has the advantage of allowing arterial grafting on the left anterior descending artery without a sternotomy incision. We present our single-center clinical experience of 66 consecutive patients.MethodsAll patients underwent MIDCAB through a left anterior small thoracotomy between August 2007 and July 2015. Preoperative, intraoperative, postoperative and follow-up data—including major adverse cardiovascular and cerebrovascular events (MACCE), graft patency, and the need for re-intervention—were collected.ResultsThe mean age of the patients was 69.4±11.1 years and 73% were male. There was no conversion to an on-pump procedure or a sternotomy incision. The 30-day mortality rate was 1.5%. There were no cases of stroke, although 2 patients had to be re-explored for bleeding, and 81.8% were extubated in the operating room or on the day of surgery. The median stay in the intensive care unit and in the hospital were 1.5 and 9.6 days, respectively. The median follow-up period was 11 months, with a 5-year overall survival rate of 85.3%±0.09% and a 5-year MACCE-free survival rate of 72.8%±0.1%. Of the 66 patients, 32 patients with 36 grafts underwent a postoperative graft patency study with computed tomography angiography or coronary angiography, and 88.9% of the grafts were patent at 9.7±10.8 months postoperatively.ConclusionMIDCAB is a safe procedure with low postoperative morbidity and mortality and favorable mid-term MACCE-free survival.

Midterm outcomes of transmyocardial laser revascularization with intramyocardial injection of adipose derived stromal cells for severe refractory angina.

IntroductionRefractory angina has limited effective therapeutic options and often contributes to frequent hospitalizations, morbidity and impaired quality of life.AimWe sought to examine midterm results of a bio-interventional therapy combining transmyocardial laser revascularization (TMLR) and intramyocardial injection of adipose derived stem cells (ADSC) in patients with refractory angina not amenable to percutaneous or surgical revascularization.Material and methodsWe included 15 patients with severe refractory angina and anterior wall ischemia who were ineligible for revascularization strategies. Adipose tissue was harvested and purified, giving the stem cell concentrate. All patients underwent left anterior thoracotomy and TMLR using a low-powered holmium : yttrium–aluminum–garnet laser and intramyocardial injection of ADSC using a combined delivery system.ResultsNo deaths or major adverse cardiovascular or cerebrovascular events were observed in the 6-month follow-up. Mean ejection fraction increased from 35% to 38%, and mean Canadian Cardiovascular Society Angina Score decreased from 3.2 to 1.4, with decreased necessity of nitrate usage. Seventy-three percent of patients reported health improvement particularly regarding general health and bodily pain. Improvement in endocardial movement, myocardial thickening and stroke volume index (35.26 to 46.23 ml/m2) on cardiac magnetic resonance imaging (MRI) was observed in 3 patients who had repeat CMR imaging after 6 months.ConclusionsOur study suggested that interventional therapy combining TMLR with intramyocardial implantation of ADSC may reduce symptoms and improve quality of life in patients with refractory angina. These early findings need further validation in large scale randomized controlled trials.

Is There a Role for Diagonal Coronary Artery Stenting in Patients Undergoing Robotic Coronary Artery Bypass Graft Surgery?

BackgroundThe efficacy of diagonal coronary artery stenting in patients undergoing robotic left internal thoracic artery-to-left anterior descending (LITA-to-LAD) anastomosis is not well defined. The objective of this study was to assess graft and stent patency in a single-stage hybrid revascularization with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery.MethodsFrom 2004 to 2014, a total of 25 patients consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD along with concomitant PCI to the diagonal coronary artery. PCI to the diagonal coronary artery was performed in the same fluoroscopy-equipped hybrid operating room.ResultsPatients were on average 66 ± 11 years with 32% female. Pre-operative characteristics of these patients included 8% with a grade 3 or 4 left ventricle, 16% with a recent MI, and 92% with CCS III/IV symptoms. There were no death, one patient required an intra-aortic balloon pump, and one patient required re-operation for bleeding. The average ICU stay was 1.1 ± 0.53 days, and the average hospital stay was 4.6 ± 2.4 days. Fitzgibbon Grade A LITA-to-LAD patency at 6-month follow-up was 100%. As well, at 6-month follow-up the DES to the diagonal coronary artery had a patency rate of 96%.ConclusionsSingle-stage hybrid revascularization strategy for bifurcating lesions of the LAD and diagonal coronary arteries with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery appears to have acceptable clinical results with excellent 6-month angiographic patency results.

Pericardial Decompression Syndrome in a Patient With Low Volume Pericardial Fluid Removal

SESSION TITLE: Critical Care 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pericardial decompression syndrome (PDS), typically presents with hemodynamic and/or pulmonary edema, immediately or up to 1-2 days following surgical pericardiostomy or pericardiocentesis. Many of reported cases noted new onset LV dysfunction, with 70% of those studies demonstrating normalization of LV systolic function. CASE PRESENTATION: A 54-year-old male without prior cardiac or pulmonary history, presented with dyspnea for 1 week and worsening pleuritic chest pain. On presentation suddenly became hypotensive 75/36, tachypneic and diaphoretic. Cardiac enzymes were negative and electrocardiogram showed no acute ST abnormalities. Computed tomography angiography chest was negative for pulmonary embolism. 2-D echocardiogram showed moderate-to-large pericardial effusion with mitral inflow abnormalities suggestive of tamponade. A left anterior thoracotomy with pericardial window & biopsy was performed and approximately 200cc of cloudy watery fluid was removed, with 594 cc removed via chest tubes over the next three days Subsequently, 36 hours later he developed increased dyspnea, requiring Bilevel Positive Airway Pressure (BiPAP) to maintain oxygenation. X-ray (Fig 1) demonstrated diffuse bilateral interstitial and alveolar disease. Treated with lasix and remained on BiPAP for 4 days, and weaned to high flow nasal cannula. Repeat X-ray (Fig 2), decreased bilateral interstitial and alveolar parenchymal. Three weeks later, the echocardiogram revealed ejection fraction, 50-55% with left ventricular diastolic dysfunction. DISCUSSION: Several mechanisms have been proposed for PDS, the hemodynamic hypothesis theorizes that with removal of the pericardial fluid, the rapid restoration of the right ventricular function would result in increased venous return and bowing of the right ventricle into the left, resulting in pulmonary edema and left-sided heart failure. In the case of the ischemic hypothesis the increased pericardial pressure would compress the epicardial arteries, which has shown to reduce coronary blood flow and may incite myocardial stunning and hibernation. Finally, elevated pericardial pressure would also promote activation of sympathetic nervous system, a high catecholamine state, and relief of pressure could unmask a pre-existing compensated LV and/or RV dysfunction. Current understanding has proposed that gradual pericardial fluid removal until the tamponade physiology resolves may reduce the risk of PDS. Interestingly, only 200cc of pericardial fluid was removed initially, with 590cc over 3 days, slowing the hemodynamic change, but still resulting in PDS, but without adverse outcome. CONCLUSIONS: Our case suggests low volume pericardial fluid removal does not negate the occurrence of PDS, but may decrease the severity. Reference #1: Rajesh, Pradhan, et al. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. EHJ-ACVC 2015, Vol. 4(2) 113-120 DISCLOSURE: The following authors have nothing to disclose: Tamer Said Ahmed, Jonathan BarreraCalix, Larry Woods, Daniel Woredekal No Product/Research Disclosure Information

Quelle chirurgie pour quelle tumeur du médiastin : expérience du service de chirurgie thoracique de CHU Hassan II de Fès

Tumors of the mediastinum are a heterogeneous group of dysembryoplatic and neoplastic diseases essentially with different prognoses and therapeutic. These tumors develop slowly and remain long asymptomatic in 40-50% of cases. The purpose of our work is to bring the result of surgical management in diagnostic and therapeutic of principal mediastinum tumors framework. We reviewed retrospectively the records of 68 patients in our training, between January 2009 and December 2013, for tumor of the mediastinum in the diagnostic framework and or therapy. There were 37 men and 31 women with a mean age of 37 years with extremes ranging from 11 to 73 years and 77.94% had an age between 11 and 50. In 39 patients, surgery had a diagnostic purpose (2 benign tumors and 37 malignancies including 27 cases of lymphomas). Curative surgery was performed in 34 patients, dominated by the tumors of thymic origin in 15 cases. Conventional surgery had involved 32 patients. The surgical approach was a total vertical sternotomy in 14 patients, in 17 patients was posterolateral thoracotomy and a left anterior thoracotomy in 1 patient. Video assisted thoracic surgery had been done in 3 patients under resection of a pleuropericardique cyst. Overall mortality was 4.41 percent. It is a death at D17 of the postoperative (thymoma with myasthenia) following a myasthenic crisis requiring a tracheotomy. A patient operated on for invasive thymoma developed myopathy and died at D44 of the postoperative following a difficulty of weaning. Another patient had a thymoma B3 benefited from 6 courses of neoadjuvant chemotherapy and then a thymectomy had presented a respiratory distress with bilateral pleural effusion, death at D10 of the postoperative by septic shock following a nosocomial infection. Tumors of the mediastinum are infrequent, discovered more often by chance. The main prognostic factor is the completeness of tumor resection without taking the break. Conventional surgery always keeps a place in our context, despite the advent of minimally invasive surgery.

Extramedullary haematopoiesis presenting with cardiac tamponade in a patient with polycythaemia vera

A 71-year-old man with a history of polycythaemia vera, diagnosed 4 years ago, presented to the emergency room with shortness of breath. A bedside echocardiogram revealed a large pericardial effusion...

A Unique Hybrid Approach to Complex Re-Do Aortic Root Surgery

We present the case of a 23-year-old male with ventriculo-aortic dehiscence and a retrosternal false aneurysm communicating to the left ventricular outflow tract (LVOT) and ascending aorta. His history included aortic valve replacement (AVR) and mitral valve (MV) repair remotely, followed by two further operations for endocarditis and aortic root abscess. The risk associated with the redo surgery required detailed planning and innovative techniques to allow it to be performed safely. These included femoral cannulation for cardiopulmonary bypass, venting the left ventricular apex via a small left anterior thoracotomy, use of a CODA® (COOK Medical, Bloomington USA) balloon to occlude the distal ascending aorta (placed via left brachial artery) and finally, the use of a PROPLEGE® (Edwards Lifesciences, Irvine, USA) retrograde cardioplegia cannula (placed via right internal jugular vein).

Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy.

IntroductionSurgical treatment of isolated left anterior descending coronary artery disease can be performed with either minimally invasive direct coronary artery bypass via a left anterior thoracotomy (MIDCAB) or off-pump coronary artery bypass via a median sternotomy (OPCAB).AimTo compare the perioperative outcomes of patients undergoing MIDCAB or OPCAB surgery.Material and methodsPatients who underwent either MIDCAB or OPCAB for isolated left anterior descending (LAD) coronary artery disease between October 2013 and December 2015 were retrospectively evaluated. Operations were carried out by the same surgical team. Preoperative, intraoperative and postoperative data of the patients were recorded for analyses.ResultsTwenty-three patients (7 females, 16 males) underwent MIDCAB surgery, and 24 patients (4 female, 20 males) underwent OPCAB surgery. The two groups were comparable regarding preoperative patient characteristics. Duration of mechanical ventilation (5.1 ±0.7 h vs. 6.6 ±0.9 h), intensive care unit stay (19.4 ±2.5 h vs. 45.8 ±5.4 h) and hospital stay (4.3 ±0.4 days vs. 5.6 ±0.8 days) were significantly shorter in the MIDCAB group (p < 0.01). Patients in the OPCAB group required significantly more blood transfusions (1.83 ±0.38 units vs. 0.17 ±0.38 units) and fresh frozen plasma use (2.33 ±0.96 units vs. 0.69 ±0.76 units) (p < 0.01). Conversion to sternotomy was not required in the MIDCAB group. There was no mortality, conversion to cardiopulmonary bypass or serious complication in either group.ConclusionsWe believe that the MIDCAB technique is more advantageous than the OPCAB technique in the treatment of patients with a critical LAD lesion.

A different application of nuss procedure in a difficult case of pectus excavatum

A 17 year-old male patient who had a history of Nuss procedure 8 months ago with a diagnosis of pectus excavatum, the bar had been removed with left anterior thoracotomy due to complications such as bar dislocation, hemothorax and infection. Minimally invasive reoperation was performed on the patient who had an asymmetrical collapse distinctive on the right side. Classical Nuss operation was not possible due to strong adhesions that developed after past procedures. At this point, instead of open surgery, we entered the thoracic cavity with two new incisions performed on the two peak points of the collapse. A tunnel was formed beneath the sternum with obtuse and sharp opposing dissections through the newly formed holes. Subsequently, subcutaneous tunnels were opened up to the new entry holes through the initial incisions that were formed left and right previously. The bar was swiped under the sternum and rotated by using the subsequent holes as entry and exit holes for the bar. It was immobilized with a stabilizer. No complications occurred in the postoperative period. Pleural adhesions are accepted as one of the most important contraindications of thoracoscopic surgery. Nevertheless, with the help of two incisions in addition to the main procedure we present our case of re-operated pectus excavatum with a minimally invasive procedure and a successful outcome.

Complex cardiac stab wound

A 50-year-old male come to the hospital victim of damage with a knife to anterior chest (precordial region) after a fight 1 h before. Cardiac tamponade was discovered by focused assessment sonography for trauma and was positive with fluid in pericardial sac. The patient was taken to the operating room. A left anterior thoracotomy was performed. There were three cardiac lesions: One was on the right ventricle, another was very near the left coronary artery (descending anterior branch), and the last one was on pulmonary artery trunk. All the three lesions were corrected with horizontal sutures with prolene 3-0, the lesion near the coronary artery was corrected with a horizontal suture under the artery. Complex cardiac wound is always a challenger to the surgeon, in this case, a cardiac lesion was so near the left coronary artery, a suture over the artery could lead to a myocardial infarction and even death of the patient.

Off Pump Robotic-Assisted LVAD (HeartWare, HVAD) Placement via Left Mini Thoracotomy

Patients who require left ventricular assist device (LVAD) placement frequently either have had previous cardiac surgery or will require future sternotomy. As a result, approaches to avoid sternotomies have been explored. Our group has had success with robotic-assisted left mini anterior thoracotomy placement of LVADs. This approach has the advantage of allowing the graft to lie in an anatomic location while avoiding the morbidity associated with a redo median sternotomy. Here we describe our technique, which can be easily adopted by those with experience in robotic-assisted thoracic procedures as well as with LVAD placement through a hemisternotomy and anterior thoracotomy.