Name: technique and patient selection criteria of right anterior mini-thoracotomy for minimal access aortic valve replacement
Uploaded: 2018-03-26T15:00:00.000+00:00
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この仕事にしたスイスの心血管系財団の助成金 (N ° 32119) 支えられ

プロトコル人間研究倫理委員会の私たちの機関のガイドラインに従います。
1. 患者の選択 (表 1)
<ol><li>14隔離された大動脈弁置換を施行した患者を識別します。</li>
	<li>これらの患者の中から選択主要胸部変形 (Kypho 側弯症)、照射の既往または右の hemi 胸郭の手術することがなくサブグループは、アクティブな心内膜炎の緊急手術等のため必要があります。</li>
	<li>昇順大動脈瘤 ≥4.5 cm 患者を除外する胸部コンピューター断層撮影 (CT) スキャンを実行します。</li>
	<li>胸部の CT (図 1と2および表 1) によって提供された測定によると最終的な決定を下します。大動脈送血法サイトと大動脈弁に近い距離に基づく、2 番目または 3 番目の肋間スペースの間を選択します。</li>
</ol>2. 手術のための準備
<ol><li>上記14として制度のガイドラインと、成人の心臓手術患者のための推奨事項を次の手術の患者を準備します。</li>
	<li>背中と左胸ドレープ前に前方に外部除細動パッドを配置します。</li>
</ol>3. 手術
<ol><li>右前ミニ開胸により心臓へのアクセス<ol>
<li>切開、肌ノテクノロジー 8 cm 以上 18 ブレード ナイフで右胸骨端の右側に 1 cm を開始選択した肋上。</li>
		<li>胸筋と、電気焼灼器を使用して肋間筋の浅層をカットします。右肺への損傷を避けるためには、Metzenbaum ハサミで右胸膜をまず入力します。その後、電気焼灼で肋間筋の開口部を拡大します。</li>
		<li>筋膜および Metzenbaum はさみを使用してそれのまわりの軟部組織から解放することによって内部右胸部椎弓根を保持します。</li>
		<li>右胸膜に軟部組織のリトラクターを挿入し、傷にそれを修正します。内部右胸部椎弓根を傷つけないように注意してください。</li>
		<li>軟部組織のリトラクターを最小限のアクセス リトラクターを置き、ゆっくりと徐々 にそれを開きます。</li>
		<li>・ カルペンティエル小説鉗子で頭側穿刺部位の脂肪をつかむし、電気焼灼でカットします。横隔膜の神経を傷つけないように注意してください。</li>
		<li>電気焼灼で右心房に心膜を開き、心膜を広めるために開口部の両側 2/0 polyglactin 宿泊縫合します。</li>
		<li>上行大動脈と右房尾側頭側心膜を開き続けます。心膜の広がりへの開口部の両側 2/0 polyglactin 宿泊縫合を配置します。</li>
		<li>上行大動脈と大動脈送血法財布の紐の配置のために準備する大動脈的遠位心膜反射を確認します。</li>
		<li>左心室の出口の配置のため右上肺静脈の解剖を確認します。</li>
		<li>上行大動脈の遠位部を公開、ピーナッツのガーゼを使用して上行大動脈を慎重に押し下げてアリス クランプにマウント。</li>
		<li>4/0 ポリプロピレン縫合糸を使用して上行大動脈遠位心膜反射ラインのすぐ下大動脈送血法の最初の財布のひもをかぶせます。4/0 ポリプロピレン縫合糸を使用して最初の 1 つの周りに 2 番目の財布-文字列を追加することによって大動脈送血法のための準備を完了します。</li>
		<li>ヘパリン/kg の 300 i. u. を与える (濃度 5,000 U/mL) IV ラインを介して。</li>
	</ol></li>
	<li>患者の心肺バイパスに接続します。<ol>
<li>まず右大腿静脈を穿刺、静脈に針を通してガイドワイヤを配置します。皮膚の 11 刃で開口部を拡大します。連続ダイレーターで穿刺部位を広げるし、経食道心エコー制御 (図 3) の下でガイドワイヤ上, 経皮的大腿静脈カニューレを紹介します。</li>
		<li>軽くプッシュ ダウン ピーナッツ ガーゼを使用して上行大動脈アリス クランプにマウントされている、財布の紐の真ん中に上行大動脈を穴をあけます。ガイドワイヤ上大動脈を cannulate します。</li>
		<li>心肺バイパスを起動し、30 ° C (図 4) に患者を冷却します。静脈の還流を改善するには、perfusionnist-50 mmHG のアシストの否定的な圧力を適用しなさい</li>
		<li>軽く左側に向かって、上大静脈を押して、4/0 ポリプロピレンのモノフィラメント縫合糸で右上肺静脈に財布のひもを配置します。左心をアンロードするのには財布のひもを左心室の出口に挿入します。</li>
	</ol></li>
	<li>弁切除と交換を準備します。<ol>
<li>クロス ・ クランプ開閉式剛性シャフトと柔軟なクランプを使用して大動脈カニューレのすぐ下大動脈。</li>
		<li>逆 L 前並非冠バルサルバ洞に至る、中国鋼管接合部のレベルを実行します。アリス クランプと、大動脈の下の尾根を撤回します。</li>
		<li>大動脈弁閉鎖不全の場合に、冠のオスティアに直接順行膠質液を提供します。</li>
		<li>大動脈を通じて非-冠状静脈洞大動脈弁上 1 cm を拡張します。左と右冠動脈のオスティアをチェックします。</li>
		<li>大動脈の下の尾根上 5/0 ポリプロピレン縫合糸を置き、大動脈弁の露出を改善する右心室の前方の面にそれを表面的に修正します。</li>
		<li>大動脈の優れた尾根上別 5/0 ポリプロピレン縫合糸を置き、大動脈弁の露出を改善する心膜を表面的にそれを修正します。</li>
		<li>遠藤鉗子で右、非冠動脈と左冠尖でつかむ順番と遠藤ハサミでそれらをします。僧帽弁、大動脈を通じて確認してください。</li>
		<li>市販バルブ sizer を使用して、挿入するバルブのラベルのサイズを決定します。Sizer 快適大動脈心室の接合部を通過するを選択します。</li>
		<li>最初は縛り付けられる遠藤針ホルダーを使用して、左と右冠動脈洞間交連の U 縫合糸とポリエステル 2/0 を編組。心室側は、縛り付けられる心室からまでの縫合に渡します。</li>
		<li>右の冠状静脈洞を完了する時計回りに縛り付けられる U 縫合糸と編みポリエステルの 2/0 の配置を続行します。</li>
		<li>時計回りの場所は、非冠動脈洞に縛り付けられる U 縫合糸とポリエステルの 2/0 を編組。</li>
		<li>右と左冠動脈洞間交連から始まる、左の冠状静脈洞に反時計回りに編みポリエステル 2/0 件縛り付けられる U 縫合糸を置くことによって環状縫合糸を完了します。</li>
		<li>ライダー針ホルダーを使用して人工弁置換術後の縫製リングにポリエステル編組の 2/0 縫合糸を渡します。</li>
		<li>人工弁をスライドさせ、バルブ ホルダーを取り外します。縫合糸を結ぶし、彼らと大動脈弁の間の任意のギャップを確認します。左と右冠オスティアに障害物がないことを確認します。</li>
		<li>Metzenbaum はさみを使用して結ばれた縫合糸をカットします。大動脈の下、優れた尾根上 5/0 露出を抜糸します。</li>
		<li>2 5/0 ポリプロピレン ヘミ縫合を実行して、大動脈を閉じます。非冠動脈洞で、大動脈のどん底に最初の 1 つを配置し、それを結ぶ。その後、逆 L 大動脈の角度に来る。わずかな張力の下で縫合糸の端を置きます。</li>
		<li>第二 5/0 ポリプロピレン実行ヘミ-縫合左端に開始および最初のヘミ縫合の最後を満たすために右側に向かってくるし、大動脈の閉鎖を続行します。2 つの端を一緒に結ぶし、それらをカットします。</li>
		<li>右心室に大動脈をアンクランプする前に心室ペーシング ワイヤを配置します。</li>
		<li>トレンデレンブルグ体位チルト動作テーブルをしましょう。完全なフローの 50% にポンプの流れを減らします。左心室の出口の穏やかな吸引の下でゆっくりと大動脈遮断14を削除します。</li>
		<li>心臓肺の完全なフローの履歴書をバイパスします。大動脈閉鎖の止血を確認します。左心室通気口を削除し、その財布のひもを結ぶ。止血を確認します。</li>
		<li>患者は 37 ° c. を rewarm します。独立した心臓肺から患者をバイパスします。安定した血液の圧力に達すると、1:1 の比率 (3 mg/kg ヘパリンの 300 U/kg に対応する) でプロタミン注入 IV でヘパリンを中和する14。</li>
		<li>最初の財布のひもを結ぶ大動脈カニューレの削除を準備します。アシスタント大動脈カニューレを取り除き、財布のひもを結ぶことを完了しなさい</li>
		<li>ダブル安全な大動脈送血法のサイトを図 8 の 4/0 ポリプロピレン縫合糸です。縫合糸をカットします。</li>
		<li>大腿静脈カニューレを削除し、20 分間の手動圧縮によって、止血をセキュリティで保護します。</li>
		<li>心膜の 1 つと 1 つの右胸水胸管を配置します。3 緩く結ばれた編組 2/0 polyglactin 縫合心膜を適応します。</li>
		<li>2 つの編組 0 polyglactin 縫合糸で肋骨を適応します。標準の方法でレイヤーの傷を閉じます。</li>
	</ol></li>
</ol>4. 術後の患者のケア
<ol><li>集中治療室に転送、次の心臓手術14標準的な術後ケアを患者を提供します。</li>
</ol>

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Surg. 92 (4), 1346-1350 (2011).</li><li>Murzi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antegrade+and+retrograde+arterial+perfusion+strategy+in+minimally+invasive+mitral-valve+surgery:+a+propensity+score+analysis+on+1280+patients.">Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.</a> Eur. J. Cardiothorac. Surg. 43 (6), 167-172 (2013).</li><li>Glauber, M., Farneti, A., Solinas, M., Karimov, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+valve+replacement+through+a+right+minithoracotomy.">Aortic valve replacement through a right minithoracotomy.</a> Multimed. Man. Cardiothorac. Surg. 2006 (1110), (2006).</li><li>D'Agostino, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Society+of+Thoracic+Surgeons+Adult+Cardiac+Surgery+Database:+2016+Update+on+Outcomes+and+Quality.">The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality.</a> Ann. Thorac. Surg. 101 (1), 24-32 (2016).</li><li>Glauber, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+anterior+minithoracotomy+versus+conventional+aortic+valve+replacement:+A+propensity+score+matched+study.">Right anterior minithoracotomy versus conventional aortic valve replacement: A propensity score matched study.</a> J. Thorac. Cardiovasc. Surg. 145 (5), 1222-1226 (2013).</li><li>Jones, D. A., Tch&#233;tch&#233;, D., Forrest, J., Hellig, F., Lansky, A., Moat, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+SURTAVI+study:+TAVI+for+patients+with+intermediate+risk.">The SURTAVI study: TAVI for patients with intermediate risk.</a> EuroIntervention. 13 (5), 617-620 (2017).</li></ol>

著者が明らかに何もありません。

このプロトコルでは分離の大動脈弁置換のミニ開胸右前のテクニックの詳細に説明し、この手順の患者選択基準を強調します。その他の治療的介入、適切な患者選択はプロシージャの成功を達成するためのキーです。この技術のための患者の検討のための最適な CT 計測正確には、このプロトコルで説明体験に基づいているし、博士グラウバーとこのフィールド10人の協力者?...

血行動態の関連性と臨床的に受信側に特に注意と診断、心臓弁の病変大動脈弁狭窄はアメリカ合衆国と先進国1,2で最も一般的な弁病理。心血管の健康の調査の患者の 2% が成長する年齢と有病率の増加が明確で、フランクの大動脈狭窄症: 歳 65-75 歳の患者で 1.3%、それらの高齢者の 75-85 年に 2.4%、85 年1より古い患者の 4%。症候を呈する患者重症大動脈弁狭窄症、大動脈弁置換術はクラス私3心臓弁膜症患者の管理のため米国心臓協会のガイドラインで勧告。
従来の外科的大動脈弁置換術 (FS) は、大動脈治療のゴールド スタンダードとして確立しているにおける胸骨正中切開弁狭窄症罹患率と死亡率の4の面で優れた結果を。これらの結果は、高齢の患者とリスクの高いプロファイルを持つ患者に治療上の適応の拡張を奨励しています。治療戦略の数は、一般集団における従来の外科的大動脈弁置換による同じ良い成果を維持するためにこれらの患者のサブセットで実装されています。これらの代替治療法の中で経カテーテル大動脈弁留置術 (TAVI) は Cribier と同僚5によって 2002 年に導入されました。瀕死の患者で最初に実行される、TAVI が急浮上した従来の外科的大動脈弁置換6、7、適性がない重症大動脈弁狭窄患者に対する治療選択肢として、または低侵襲として高における患者への手術のアプローチはリスク8,9です。
にもかかわらず、選択した患者のサブセットのタヴィの改善の結果、症候性大動脈弁狭窄症の多くの患者はまだ外科的大動脈弁置換術のための候補者であります。これらの患者で FS 大動脈弁置換術、心臓外科医によって最も頻繁に使用されるアプローチです。それにもかかわらず、外科的外傷10を減らすことの理論的根拠と様々 な「低侵襲」技術が開発されています。これらのすべての最小アクセス手法術後の痛みを軽減し、入院期間を短縮し、グローバル コスト10を保存可能性があります患者の回復を加速による患者の快適性の向上を目指した。低侵襲切開アプローチ上部ヘミ-胸骨 (UHS) と右前ミニ開胸 (RAMT) 文献11で報告の主な手法となっています。大動脈弁置換術の右前小開最初 Benettiらによって報告されました。12、および上部のヘミ胸骨最初いくつかの著者11によって記述されていた。瘢痕の選択肢に加えて 2 つの動脈の血流の戦略が使用されている: i) 周辺の大腿動脈カニュレーション、ii) 中心部大動脈送血法よりもより頻繁に採用されています。
低侵襲大動脈弁置換術の患者転帰の改善が報告された、にもかかわらず限られた手術分野および末梢動脈灌流戦略13の短所についての懸念リードする多くの心臓外科医大動脈弁置換術のための最小限のアクセス アプローチの潜在的な利点から恩恵を受ける患者がさせません。このプロトコルの目的は、右前ミニ開胸肋骨切除/骨折と動脈灌流の中心部大動脈送血法により低侵襲大動脈弁置換術のこの手法の詳細に説明することです。このプロトコルに従うことによって心臓外科医の大きい数は、特定の患者グループで大動脈弁置換術の右前のミニ開胸を実行できます。患者の選択および技術の制限事項を説明します。初期の結果は、完全胸骨によって分離された大動脈弁置換術を受ける患者のコホートの比較されます。

<table><tbody><tr><td>&lt;strong&gt;Heart surgery infrastructure:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Heart Lung Machine</td><td>Stockert</td><td>SIII</td><td></td></tr><tr><td>EOPA 24Fr. arterial cannula</td><td>Medtronic</td><td>77624</td><td></td></tr><tr><td>FemFlex arterial cannula</td><td>Edwards</td><td>FEMII20A</td><td></td></tr><tr><td>Quickdraw 25Fr. femoral venous cannula</td><td>Edwards</td><td>QD25</td><td></td></tr><tr><td>Biomedicus 25Fr. Nextgen venous cannula</td><td>Medtronic</td><td>96670-125</td><td></td></tr><tr><td>LV vent catheter 17Fr.</td><td>Edwards</td><td>E061</td><td></td></tr><tr><td>Antegrade 9Fr. cardioplegia cannula</td><td>Edwards</td><td>AR012V</td><td></td></tr><tr><td>Coronary artery ostial cannula 90&amp;deg;</td><td>Medtronic</td><td>30155</td><td></td></tr><tr><td>Coronary artery ostial cannula 45&amp;deg;</td><td>Medtronic</td><td>30255</td><td></td></tr><tr><td>&lt;strong&gt;Soft tissue retractor&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>STAR soft tissue atraumatic retractor</td><td>Estech</td><td>EC400220</td><td></td></tr><tr><td>Soft tissue retractor</td><td>Edwards</td><td>TRM</td><td></td></tr><tr><td>Electrocautery</td><td>Covidien</td><td>Force FX&lt;sup&gt;TM&lt;/sup&gt;</td><td></td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Polypropylene 4/0</td><td>Ethicon</td><td>8871H</td><td></td></tr><tr><td>Polypropylene 5/0</td><td>Ethicon</td><td>8870H</td><td></td></tr><tr><td>Braided polyesther 2/0 ligature with polybutylate coating&amp;nbsp;</td><td>Ethicon</td><td>X305H</td><td></td></tr><tr><td>Braided polyesther2/0 with pledgets V5</td><td>Ethicon</td><td>MEH7715N</td><td></td></tr><tr><td>Braided polyglactin 2/0 suture</td><td>Ethicon</td><td>V114H</td><td></td></tr><tr><td>Braided polyglactin 0 suture</td><td>Ethicon</td><td>W9996</td><td></td></tr><tr><td>&lt;strong&gt;Drugs:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Midazolam</td><td>Roche Pharma</td><td>N05CD08</td><td></td></tr><tr><td>Rocuronium</td><td>MSD Merck Sharp &amp;amp; Dohme&amp;nbsp;</td><td>M03AC09</td><td></td></tr><tr><td>Propofol</td><td>Fresenius Kabi</td><td>N01AX10</td><td></td></tr><tr><td>Fentanil</td><td>Actavis</td><td>N01AH01</td><td></td></tr><tr><td>Heparin</td><td>Braun</td><td>B01AB01</td><td></td></tr><tr><td>Protamin</td><td>MEDA Pharmaceutical</td><td>V03AB14</td><td></td></tr><tr><td>Custodiol cardioplegia solution</td><td>Dr. F. K&amp;ouml;hler Chemie GmbH</td><td>B05CX10</td><td></td></tr><tr><td>&lt;strong&gt;Instruments:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Window access retractor SI</td><td>Estech</td><td>400-400</td><td></td></tr><tr><td>SI retractor blade 40W50L</td><td>Estech</td><td>400-172</td><td></td></tr><tr><td>Ceramo atraumatic forceps 2.8x15/350</td><td>Fehling</td><td>FE-MRA-3</td><td></td></tr><tr><td>Ceramo HCR valve forceps 3.0x15/350</td><td>Fehling</td><td>FE-MRA-0</td><td></td></tr><tr><td>Ceramo HCR needle holder 2x10/340</td><td>Fehling</td><td>FE-MRB-2</td><td></td></tr><tr><td>Ceramo TC HCR needle holder curved 3x10/340</td><td>Fehling</td><td>FE-MRG-9</td><td></td></tr><tr><td>Ceramo HCR valve scissors 350</td><td>Fehling</td><td>FE-MRA-7</td><td></td></tr><tr><td>Ceramo HCR curved scissors 350</td><td>Fehling</td><td>FE-MRA-6</td><td></td></tr><tr><td>Cygnet flexible arched aortic clamp</td><td>Vitalitec</td><td>V10143</td><td></td></tr><tr><td>Intrack insert set double traction</td><td>Vitalitec</td><td>N10122</td><td></td></tr><tr><td>Dissection forceps Carpentier</td><td>Delacroix-Chevalier</td><td>DC13110-28&amp;nbsp;</td><td></td></tr><tr><td>Scissors Metzenbaum</td><td>Delacroix-Chevalier</td><td>B351751</td><td></td></tr><tr><td>Needle holder Ryder</td><td>Delacroix-Chevalier</td><td>DC51130-20&amp;nbsp;</td><td></td></tr><tr><td>Dissection forceps DeBakey</td><td>Delacroix-Chevalier</td><td>DC12000-21&amp;nbsp;</td><td></td></tr><tr><td>Lung retractor</td><td>Delacroix-Chevalier</td><td>B803990</td><td></td></tr><tr><td>Allis clamp</td><td>Delacroix-Chevalier</td><td>DC45907-25&amp;nbsp;</td><td></td></tr><tr><td>O&amp;rsquo;Shaugnessy Dissector</td><td>Delacroix-Chevalier</td><td>B60650</td><td></td></tr><tr><td>18 blade knife</td><td>Delacroix-Chevalier</td><td>B130180</td><td></td></tr><tr><td>11 blade knife</td><td>Premiere</td><td>9311-2PK</td><td></td></tr><tr><td>Leriche haemostatic clamp</td><td>Delacroix-Chevalier</td><td>B86555</td><td></td></tr><tr><td>&lt;strong&gt;Data analysis&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Mann-Whitney and Chi-square tests</td><td>GraphPad</td><td>Prism 7</td><td></td></tr></tbody></table>

technique and patient selection criteria of right anterior mini-thoracotomy for minimal access aortic valve replacement

大動脈弁狭窄は先進国で最も普及している心臓弁膜をなっており、これらの人口の高齢化によるものです。病理の発生率は、65 年後の年齢の成長とともに増加します。胸骨正中切開従来の外科的大動脈弁置換術では、症候性大動脈弁狭窄症に対する治療のゴールド スタンダードをされています。しかし、患者のリスク プロファイルを悪化させると他の治療戦略を確立された手術によって得られる優秀な結果を維持する試みで導入されています。これらの方法の 1 つは、経カテーテル大動脈弁留置術によって表されます。ハイリスク患者で症候性大動脈弁狭窄症に対する治療の成果は、経カテーテル大動脈弁置換術で改善している、この状態で多くの患者まま外科的大動脈弁置換術のための候補者。候補者の外科的大動脈弁置換術の患者に外科的外傷を減らすために、低侵襲アプローチは、過去 10 年間の間に関心を集めています。1993 年に大動脈弁置換術の右前方開胸術の導入、以来右前ミニ開胸と上部ヘミ胸骨大動脈の最小限のアクセスを実行する心臓外科医の間で切開方法が主流となっています。弁置換。切開の位置は、横にある動脈カニュレーション サイトは大動脈弁置換術のための最小限のアクセス技術の 2 番目の主要なランドマークを表します。2 つの最も頻繁に使用される動脈カニュレーション サイトには中央大動脈および末梢大腿アプローチが含まれます。これらの患者に外科的外傷を減らすことを目的として中央大動脈送血法サイトで右前のミニ開胸アプローチしました。このプロトコルでは、低侵襲大動脈弁置換術の手法について詳しく説明し、心臓コンピューター トモグラフィ測定を含む、患者選択基準の推奨事項を示します。適応とその選択肢と同様に、この手法の限界を説明します。

統計分析 (± SD を手段として表示される) 連続変数の表 2表 3 表 4非パラメトリック マン ・ ホイットニー検定を用いて行われます。カテゴリ変数の表 2表 3 表 4の割合で、カイ二乗検定で比較すると。統計解析を行い, pにセットされた統計的有意性しきい値と市販のソフトウェアを使用?...

Watch this Scientific Journal Video about Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement at JoVE.com

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

技術と最小限のアクセス大動脈弁置換のミニ開胸右前の患者選択基準

このプロトコルの目的は、右前のミニ開胸して中心部大動脈送血法の低侵襲大動脈弁置換術のテクニックの詳細に説明することです。この手法が潜在的患者の快適性を高める、術後合併症を減らすことによって、滞在期間、グローバル コストを下げることを促進するため。

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

technique-patient-selection-criteria-right-anterior-mini-thoracotomy

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

11.6K ビュー.  Institut de Cardiologie. このプロトコルの目的は、右前のミニ開胸して中心部大動脈送血法の低侵襲大動脈弁置換術のテクニックの詳細に説明することです。この手法が潜在的患者の快適性を高める、術後合併症を減らすことによって、滞在期間、グローバル コストを下げることを促進するため。

ビデオ: Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

マウスにおける低侵襲横大動脈狭窄

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

医学

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

小型大動脈瘤患者におけるステントレス大動脈異種移植による全大動脈弁置換術

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH.
Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%.
In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

The aim of this protocol is to describe step-by-step the technique of minimally invasive transverse aortic constriction (TAC) in mice. By elimination of intubation and ventilation which are mandatory for the commonly used standard procedure, minimally invasive TAC simplifies the operative procedure and reduces the strain put on the animal.

左室肥大の誘導マウスにおける低侵襲の横大動脈狭窄のテクニック

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

弁温存大動脈の大動脈弁再置換術の標準化された技術のルート交換

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Semi-Minimal Invasive Method to Induce Myocardial Infarction in Rats and the Assessment of Cardiac Function by an Isolated Working Heart System

Myocardial infarction (MI) remains the main contributor to morbidity and mortality worldwide. Therefore, research on this topic is mandatory. An easily and highly reproducible MI induction procedure is required to obtain further insight and better understanding of the underlying pathological changes. This procedure can also be used to evaluate the effects or potency of new and promising treatments (as drugs or interventions) in acute MI, subsequent remodeling and heart failure (HF). After intubation and pre-operative preparation of the animal, an anesthetic protocol with isoflurane was performed, and the surgical procedure was conducted&#160;quickly. Using a minimally invasive approach, the left anterior descending artery (LAD) was located and occluded by a ligature. The occlusion can be performed acutely for subsequent reperfusion (ischemia/reperfusion injury). Alternatively, the vessel can be ligated permanently to investigate the development of chronic MI, remodeling or HF. Despite common pitfalls, the drop-out rates are minimal. Various treatments such as remote ischemic conditioning can be examined for their cardioprotective potential pre-, peri- and post-operatively. The post-operative recovery was quick as the anesthesia was precisely controlled and the duration of the operation was short. Post-operative analgesia was administered for three days. The minimally invasive procedure reduces the risk of infection and inflammation. Furthermore, it facilitates rapid recovery. The &#8220;working heart&#8221; measurements were performed ex vivo and enabled precise control of preload, afterload and flow. This procedure requires specific equipment and training for adequate performance. This manuscript provides a detailed step-by-step introduction for conducting these measurements.

This article presents an efficient method to perform myocardial ischemia and subsequent chronic reperfusion in rats using a minimally invasive approach. In addition, left ventricular hemodynamic function of rats is assessed by echocardiography and isolated working heart methods.&#160;

ラットの心筋梗塞を誘導する半最小侵襲法と、単離した働く心臓システムによる心機能の評価

Myocardial infarction (MI) remains the main contributor to morbidity and mortality worldwide. Therefore, research on this topic is mandatory. An easily ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Chronic Ovine Model of Right Ventricular Failure and Functional Tricuspid Regurgitation

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to suboptimal clinical results. We set out to establish a chronic ovine model of FTR and right heart failure to investigate the mechanisms of FTR. Twenty adult male sheep (6-12 months old, 62 &#177; 7 kg) underwent a left thoracotomy and baseline echocardiography. A pulmonary artery band (PAB) was placed and cinched around the main pulmonary artery (PA) to at least double the systolic pulmonary artery pressure (SPAP), inducing right ventricular (RV) pressure overload and signs of RV dilatation. PAB acutely increased the SPAP from 21 &#177; 2 mmHg to 62 &#177; 2 mmHg. The animals were followed for 8 weeks, symptoms of heart failure were treated with diuretics, and surveillance echocardiography was used to assess for pleural and abdominal fluid collection. Three animals died during the follow-up period due to stroke, hemorrhage, and acute heart failure. After 2 months, a median sternotomy and epicardial echocardiography were performed. Of the surviving 17 animals, 3 developed mild tricuspid regurgitation, 3 developed moderate tricuspid regurgitation, and 11 developed severe tricuspid regurgitation. Eight weeks of pulmonary artery banding resulted in a stable chronic ovine model of right ventricular dysfunction and significant FTR. This large animal platform can be used to further investigate the structural and molecular basis of RV failure and functional tricuspid regurgitation.

Right ventricular failure and functional tricuspid regurgitation are associated with left-sided heart disease and pulmonary hypertension, which contribute significantly to morbidity and mortality in patients. Establishing a chronic ovine model to study right ventricular failure and functional tricuspid regurgitation will help in understanding their mechanisms, progression, and possible treatments.

右室不全と機能性三尖弁逆流の慢性ヒツジモデル

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to ...

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

鼠径部血管の経皮的カニュレーションによる完全内視鏡的僧帽弁修復術

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

圧力過負荷誘発性心不全を研究するための上行大動脈バンディング

A Minimally Invasive Model of Aortic Stenosis in Swine

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition.
The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

著者スポットライト:信頼性と再現性のある心血管研究のための低侵襲大動物モデルの開発 

This protocol describes a minimally invasive surgical procedure for ascending aortic banding in swine.

ブタの大動脈弁狭窄症の低侵襲モデル

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological ...

技術と最小限のアクセス大動脈弁置換のミニ開胸右前の患者選択基準

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マウスにおける低侵襲横大動脈狭窄

小型大動脈瘤患者におけるステントレス大動脈異種移植による全大動脈弁置換術

左室肥大の誘導マウスにおける低侵襲の横大動脈狭窄のテクニック

弁温存大動脈の大動脈弁再置換術の標準化された技術のルート交換

ラットの心筋梗塞を誘導する半最小侵襲法と、単離した働く心臓システムによる心機能の評価

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

右室不全と機能性三尖弁逆流の慢性ヒツジモデル

鼠径部血管の経皮的カニュレーションによる完全内視鏡的僧帽弁修復術

ブタの大動脈弁狭窄症の低侵襲モデル

ブタの大動脈弁狭窄症の低侵襲モデル