Aortic annular enlargement is an important adjunct to aortic valve replacement in patients with a small aortic annulus and restricted aortic root anatomy. The Y-incision technique facilitates implantation of a larger prosthetic valve, reducing the risk of prosthesis-patient mismatch and improving postoperative haemodynamics. This video tutorial demonstrates Y-incision aortic annular enlargement combined with bioprosthetic aortic valve replacement in a 67-year-old woman with symptomatic severe aortic stenosis and a severely restricted aortic root anatomy. Preoperative imaging revealed a 19 mm aortic annulus, small aortic root dimensions and a narrow sinotubular junction. Following extensive aortic root mobilization, a Y-shaped incision was extended through the aortomitral curtain and reconstructed using an arc-shaped patch modification to facilitate annular, root and sinotubular junction enlargement. The enlarged annulus allowed implantation of a 23 mm bioprosthetic valve with careful commissural alignment and root reconstruction. Postoperative imaging demonstrated excellent valve position and function without paravalvular leak. Peak and mean transvalvular gradients were 14 and 8 mmHg at discharge, and remained stable at 4-month follow-up. This video tutorial highlights the key technical steps of Y-incision aortic annular enlargement and demonstrates excellent early haemodynamic results following implantation of an appropriately sized prosthesis.
Unicuspid aortic valves in adolescents frequently present with combined stenosis and regurgitation but often retain sufficient native tissue to allow reconstructive repair. We present a tricuspidization technique based on selective replacement of a dysplastic cusp with autologous pericardium and creation of two neocommissures to restore symmetric leaflet closure. The operation converts a functionally unicuspid valve into a tricuspid configuration while preserving native leaflet tissue. In the presented case, the repair resulted in competent valve function with low transvalvular gradient at follow-up. This technique may serve as a growth-preserving strategy to postpone definitive valve replacement in selected paediatric patients.
This case report describes the robot assisted resection of a 70 year old man's anterior mediastinal mass. Preoperative imaging showed an 85 × 45 mm thymic squamous cell carcinoma invading the pericardium and occluding the left innominate vein. After neoadjuvant chemotherapy, a bilateral robotic approach was used. The phrenic nerves and great vessels were skeletonized; the left innominate vein was encircled and transected with a vascular stapler; the mass was mobilized off the sternum; the pericardium was opened and resected en bloc with the tumour; and the robot was re docked on the right to dissect the right phrenic nerve and control the superior vena cava, which underwent stapled plasty before division of the left innominate vein. Reconstruction included a bovine pericardial patch. Operative time was 300 minutes with no intraoperative complications; the patient developed transient atrial fibrillation and was discharged on Day 9. Final pathology confirmed an R0 resection. This case highlights that robot assisted thoracic surgery can safely manage complex mediastinal tumours involving the pericardium and great vessels, offering advantages in blood loss and recovery compared with sternotomy.
This video tutorial demonstrates a robotic-assisted left lower lobectomy in a 71-year-old female with critical exercise capacity. Preoperative evaluation revealed a 32 mm cavitated tumour in the left lower lobe. While pulmonary function tests showed a preserved forced expiratory volume in 1 second (84%), the peak oxygen consumption (VO2peak) was critically low at 5.9 mL/kg/min. Multidisciplinary assessment attributed this prohibitive value to severe musculoskeletal impairment rather than cardiopulmonary exhaustion. A robotic approach was selected to minimize chest wall trauma. The procedure involved standard hilar dissection, complete fissure division and systematic lymph node dissection. The patient experienced an uneventful recovery, with chest tube removal on postoperative Day (POD) 2 and hospital discharge on Day 3. Final pathology confirmed a 40 mm papillary adenocarcinoma (Stage IB) with micropapillary and solid components, and negative margins and lymph nodes.
Chronic superior vena cava obstruction is a recognized complication of transvenous pacemaker and implantable cardioverter-defibrillator leads. A 39-year-old woman with genetically confirmed left ventricular non-compaction cardiomyopathy and a transvenous implantable cardioverter-defibrillator placed for primary prevention developed progressive superior vena cava syndrome. Computed tomography angiography demonstrated chronic occlusion of the superior vena cava and left brachiocephalic vein with extensive collateralization. Endovascular recanalization was attempted from femoral, bilateral internal jugular, and left brachial approaches, but no guidewire could traverse the multilevel chronic occlusion, precluding balloon angioplasty or stenting. Open reconstruction was performed. The left femoral-popliteal vein was harvested, inverted and rendered valve-free. Lead extraction was performed in two stages: the generator and extrathoracic lead were mobilized using a locking stylet and mechanical extraction sheaths, followed by intrathoracic lead removal through median sternotomy and a controlled superior vena cava venotomy. The autologous graft was anastomosed end-to-side to the right subclavian vein, tunnelled through the mediastinum, and anastomosed to the superior vena cava venotomy. Doppler ultrasound confirmed excellent flow. Follow-up imaging demonstrated a patent graft with marked symptomatic improvement.
Hypertrophic obstructive cardiomyopathy is characterized by asymmetric septal hypertrophy and dynamic left ventricular outflow tract obstruction, often associated with systolic anterior motion of the mitral valve. In symptomatic patients who are not responders to medical therapy, surgical septal myectomy is considered the gold standard. We present a case of totally endoscopic transaortic septal myectomy performed in a symptomatic patient with severe left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. Preoperative imaging demonstrated marked asymmetric septal hypertrophy, hyperdynamic ventricular function and significant outflow tract gradient. The procedure was performed using a totally endoscopic approach with femoro-femoral cardiopulmonary bypass and transthoracic aortic cross-clamping. After the pericardial opening and aortotomy, a transaortic septal myectomy was performed under three-dimensional endoscopic visualization. Intraoperative transoesophageal echocardiography confirmed resolution of systolic anterior motion and marked reduction of outflow tract obstruction. Postoperative transthoracic echocardiography demonstrated preserved ventricular function and absence of systolic anterior motion, and a peak gradient of 18 mmHg. This case highlights the feasibility and reproducibility of a totally endoscopic approach for septal myectomy, combining the effectiveness of conventional surgery with the advantages of a non-sternotomy technique.
The mitral valve is conventionally accessed through a left atriotomy; however, adequate visualization may be challenging in selected patients, particularly those undergoing redo surgery, minimally invasive procedures, or with a small or non-compliant left atrium. In such cases, a transseptal interatrial approach can provide improved exposure of the mitral apparatus while facilitating concomitant tricuspid valve procedures. The limited transseptal (LTS) approach represents a partial, anatomy-preserving modification of the classic extended vertical transatrial septal incision. By confining the septal incision to the region of the fossa ovalis, and avoiding superior extension toward the atrial roof, this technique provides sufficient mitral valve exposure while minimizing the risk of injury to the sinus node artery and atrial conduction tissue. Alternative strategies, including the superior transseptal approach and the extended vertical transseptal incision have been associated with a higher incidence of atrial conduction disturbances and postoperative pacing requirements. In contrast, the LTS approach preserves atrial anatomy and reduces surgical trauma while maintaining excellent access to both atrioventricular valves. This video tutorial outlines the anatomical principles, indications and step-by-step surgical technique of the LTS approach, highlighting technical pearls and potential pitfalls to facilitate its safe and reproducible application in contemporary mitral valve surgery.
Surgical revascularization carries a class I recommendation for the treatment of ischaemic cardiomyopathy and multivessel coronary artery disease, yet coronary artery bypass grafting carries substantial risk of postoperative low cardiac output syndrome and subsequent mortality in patients with severe left ventricular systolic dysfunction. Off-pump coronary artery bypass grafting avoids cardiopulmonary bypass and cardioplegic arrest, but may not be feasible in severe left ventricular systolic dysfunction because of intraoperative haemodynamic instability and impaired exposure of the dilated heart. Pre-emptive mechanical circulatory support may resolve these tensions. This video tutorial presents the Impella 5.5-supported coronary artery bypass procedure, as an application of the 'protected cardiac surgery' concept. During this procedure, a surgically implanted microaxial flow pump (Impella 5.5) enables complete off-pump revascularization. Patient selection, preoperative planning and the step-by-step procedure are detailed, and illustrated by a patient with an ejection fraction of 19%, severe left ventricular dilatation, viable myocardium and three-vessel disease. The Impella 5.5-supported coronary artery bypass procedure was performed successfully, with planned postoperative support maintained, and eventual awake explantation. Consequently, this video tutorial demonstrates the feasibility and reproducibility of the Impella 5.5-supported coronary artery bypass procedure, allowing the conduct of future prospective comparative studies to define its eventual role, and to establish how pre-emptive support may improve outcomes.
Radical thymectomy has withstood the test of time as the standard procedure for treating thymic masses. Minimally invasive thymectomy, especially when performed using a surgical robot, has resulted in superior oncological clearance from the ipsilateral to the contralateral phrenic nerves, while drastically reducing the morbidity associated with median sternotomy. There is sparse literature on how to perform this procedure using a modular robotic system, which is gaining popularity. Here, we present our technique of robotic radical thymectomy through a right thoracic approach using a modular surgical robot, the Hugo RAS system, with emphasis on port positions, OT set-up and surgical steps.
Thoracoscopic intercostal nerve cryoablation is increasingly used as an adjunct to the Nuss procedure for pectus excavatum to reduce postoperative pain, yet detailed stepwise descriptions remain limited. This video tutorial presents a practical, structured description of the operative technique with emphasis on reproducible procedural steps. The patient is placed supine with both arms elevated, and single lung ventilation is established, commencing with the left-sided procedure. Thoracoscopic access is obtained through small lateral ports, followed by carbon dioxide insufflation to improve visualization. The thoracoscope is introduced to identify the third to eighth intercostal spaces. A cryoprobe is inserted through a lateral intercostal access point and positioned directly onto the intercostal nerve along the inferior border of each rib. A palpation instrument is used to retract the lung and facilitate safe exposure of the target nerve. Once correct positioning is confirmed, a controlled freezing cycle is initiated to achieve targeted nerve ablation, after which complete thawing is ensured before probe repositioning. The process is repeated sequentially for each intercostal level. After completion of cryoablation, an adjunctive intercostal block may be administered, followed by reinflation of the lung under thoracoscopic visualization. After the left-sided procedure is completed, it may be reproduced on the right. Once the right-sided procedure is completed, standard Nuss bar placement is performed. Technical pitfalls related to probe positioning, rib level identification, and tissue protection are highlighted to support safe and consistent application of the technique.
Tracheal resection/reconstruction is among the most technically demanding procedures in thoracic surgery, traditionally requiring open approaches with complex airway management. The emergence of robotic-assisted surgery combined with venovenous extracorporeal membrane oxygenation (VV-ECMO) offers a minimally invasive alternative providing enhanced surgical precision, reduced postoperative morbidity and optimal apnoeic operative conditions. We report a robotic tracheal resection/reconstruction under VV-ECMO in a 65-year-old patient with a tracheal mucoepidermoid carcinoma following endoscopic debulking with incomplete margins. Key surgical highlights include a percutaneous VV-ECMO enabling complete apnoeic conditions, lymph node dissection to initiate progressive tracheal exposure, preserving the vagus nerve and tracheal vascularization, an original fluorescence-guided transillumination technique for intraoperative resection margin identification, and end-to-end anastomosis using three continuous V-Loc sutures. The patient was discharged on postoperative Day 7 with no major complications. Resection was finally complete, and anastomotic integrity was confirmed at two-month bronchoscopy. Given the rarity of this tumour and the steep learning curve of robotic airway surgery, a step-by-step video tutorial was necessary to establish a reproducible, didactic framework for this combined approach.
Resectional and non-resectional techniques are both well established in mitral valve repair. While we generally prefer resectional methods when feasible, neochordae represent an essential complementary tool to maximize repair rates. Herein, we present our adaptation for the robotic approach and highlight key principles for using neochordae to achieve durable repair.
Reintervention after truncus arteriosus repair is frequently driven by progressive neoaortic (truncal) valve regurgitation. In many patients, valve dysfunction is primarily associated with annular and root dilatation rather than intrinsic leaflet pathology. We present a 6-year-old child with prior neonatal repair of truncus arteriosus who developed severe truncal valve regurgitation in the setting of marked annular dilatation and quadricuspid truncal valve. The patient underwent truncal valve repair by tricuspidization, annular reduction and root stabilization. Replacement of the right pulmonary valve was performed. Postoperative echocardiography demonstrated excellent truncal valve function with only a trace of regurgitation. At 2-month follow-up, valve function remained stable. This case highlights the importance of annular reduction and valve-preserving strategies in truncal valve surgery.
Neoaortic valve repair after arterial switch operation can be challenging due to altered valve geometry and the absence of an ideal material for leaflet augmentation. We report repair of severe neoaortic valve regurgitation in a 22-month-old child using autologous pulmonary artery wall for cusp augmentation. A geometry-driven approach was applied, including augmentation of all cusps to increase coaptation surface and enlargement of the right sinus of Valsalva. This demonstrates feasibility of the neoaortic valve repair with autologous living pulmonary artery wall.
Extensive mitral annular calcification represents a major technical challenge in mitral valve surgery and is associated with increased operative mortality and morbidity, including atrioventricular disruption, circumflex artery injury and prosthetic valve dehiscence. Management strategies remain controversial, including in patients suitable for transcatheter interventions. We present a case of severe symptomatic mitral regurgitation in an elderly female patient with extensive circumferential mitral annular calcification. Preoperative imaging confirmed severe mitral regurgitation with restricted calcified mitral leaflets and preserved left ventricular systolic function. Transcatheter mitral valve implantation was considered, but deemed unsuitable because of annular size. The patient therefore underwent endoscopic mitral valve replacement through a right minithoracotomy using femoro-femoral cardiopulmonary bypass. An endoaortic balloon was used to arrest the heart with cardioplegia. After excision of the native valve and limited debridement of calcification, a bioprosthetic mitral valve was implanted and tied with pledgeted braided sutures and an automatic suture knotting device (CorKnot). A bovine pericardial patch was sutured to the posterior portion of the prosthetic sewing ring using a posterior skirt technique to reinforce the posterior annulus and reduce paravalvular leakage risk. Postoperative echocardiography demonstrated a well-functioning prosthetic valve with preserved ventricular function and a trivial paravalvular leak.
We present a case of an otherwise healthy young male with a 5.0 cm aortic root aneurysm complicated by a thin "sinking" right sinus of Valsalva who underwent a valve-sparing aortic root replacement with a planned right ventriculotomy.
We present the case of a young man with a prior homograft root replacement and a subsequent transcatheter aortic valve-in-valve, who presented with a root pseudoaneurysm and severe aortic regurgitation due to valve degeneration from endocarditis. The surgical procedure involved the explant of transcatheter aortic valve implantation prosthesis using a snare technique, removal of the homograft and a subannular Bentall procedure. This case illustrates the technical challenges and the "lifetime management" strategy required for complex redo aortic interventions in younger patients.
We report the case of a 52-year-old woman with severe tricuspid regurgitation due to Ebstein's anomaly. She underwent surgery through a 2.5 cm right minithoracotomy incision under three-dimensional endoscopic visualization. After identification of the atrialized right ventricle and the displaced attachments of the septal leaflet and part of the posterior leaflet within the atrialized segment, plication of the atrialized portion was performed to exclude it. The displaced leaflet attachment level within the atrialized right ventricle was regarded as the functional tricuspid annulus and served as the site for annuloplasty. Tricuspid annuloplasty was then performed using a semi-rigid partial ring, and leaflet coaptation was further improved by an edge-to-edge valvuloplasty. Postoperative echocardiography showed trace tricuspid regurgitation, and computed tomography demonstrated resolution of the atrialized right ventricle. She was discharged home in good condition.
A 7-year-old cyanotic child with unrepaired tetralogy of Fallot, a single coronary artery arising from the left coronary sinus, and suspected pulmonary thromboembolism underwent complete intracardiac repair. This video tutorial demonstrates a comprehensive surgical strategy that simultaneously addresses intracardiac repair and pulmonary thromboendarterectomy while safely managing a rare coronary anomaly. Following median sternotomy and establishment of cardiopulmonary bypass, the pulmonary arteries were carefully inspected because preoperative imaging suggested thrombotic material within the pulmonary artery. Pulmonary arteriotomy revealed organized thromboembolic material, which was meticulously removed, restoring pulmonary arterial patency. Attention was then directed to correction of the congenital cardiac defect. The large malaligned ventricular septal defect was closed with a polyester patch through the right atrial approach. Severe right ventricular outflow tract obstruction caused by infundibular and valvular pulmonary stenosis was relieved by extensive muscle resection and pulmonary valvotomy.
Minimally invasive surgery is the standard of care for lung resections in patients with early-stage non-small cell lung cancer. Non-intubated thoracic surgery, relying on spontaneous ventilation under sedation and locoregional anaesthesia, has emerged as an alternative to general anaesthesia with potential advantages for patients. The application of non-intubated thoracic surgery to video-assisted thoracic surgery to perform anatomical lung resections has already been described and aims at merging the benefits of the two techniques to improve the patient postoperative course. Robotic-assisted thoracic surgery represents a further refinement of minimally invasive techniques, offering several advantages over video-assisted thoracic surgery in complex procedures. To the best of our knowledge, this is the first case of a robotic-assisted lung segmentectomy performed without endotracheal intubation and under locoregional anaesthesia and sedation.
