The Personalized External Aortic Root Support (PEARS) procedure is a contemporary strategy in the prophylactic management of aortic aneurysms, albeit formerly limited to the aortic root and ascending aorta. We describe an innovative surgical approach, termed the Personalized External Aortic Arch Support procedure, that enables the ExoVasc PEARS prosthesis (eXstent, England) to be extended in cases of concomitant aortic arch dilatation. This modification applies external reinforcement principles to “stabilize,” and thus “spare,” the native aorta from the aortic valve to the distal aortic arch; utilized with favorable early outcomes in Australasia. Advantages include the avoidance of circulatory arrest and cardiopulmonary bypass, with no interruption to cerebral perfusion. We consider that this novel technique could broaden the application of PEARS in selected patients to reduce the risk of aortic arch complications and the need for re-intervention.
The Ross procedure has re-emerged as an important surgical option for aortic valve replacement in carefully selected patients, supported by long-term data demonstrating excellent hemodynamics, durability, and safety. Notably, it remains the only operation capable of restoring normal life expectancy in select patients requiring aortic valve replacement. Despite these advantages, the procedure is performed by few surgeons worldwide and is often undertaken at low volumes with consequent unacceptable risk. The principal barrier to wider adoption is the complexity of the operation, with autograft implantation representing its most nuanced and technically demanding component. This article aims to demystify this critical aspect of the Ross procedure by presenting a simplified and systematic approach to autograft assessment and implantation, with the goal of enhancing reproducibility, safety, teachability, and utilization.
Severe pulmonary valve insufficiency complicates the management of many procedures requiring right ventricular outflow tract (RVOT) reconstruction. Originally described in Tetralogy of Fallot (TOF), neopulmonary valve reconstruction using right atrial (RA) appendage tissue has proven effective in restoring RVOT competence, out to at least out to 8-years in our experience. Certain technical considerations can facilitate efficient and reliable neopulmonary valve reconstruction. As surgeons gain experience and proficiency from routine cases, they can extend the application of RA appendage pulmonary valve reconstruction to more complex repairs.
The cardiac surgery community increasingly recognizes coronary surgery as a subspecialty requiring advanced technical skills and training. Every aspect of coronary artery bypass grafting has evolved to bring important benefits to patients and also greater complexity in operative technique. To harness the benefits of advanced coronary surgery and avoid associated pitfalls, mastery of the technical nuances must be achieved. This document provides a step-by-step primer on the techniques for routinely performing safe and reliable all-arterial no-aortic-touch off-pump coronary artery bypass grafting, summarizing lessons learned during a decade of evolution in a focused coronary surgical program.
Management of severe mitral valve stenosis in small children is challenging. Mitral valve replacement is often required and associated with high mortality and morbidity when performed in infants and young children. The technique of mitral valve reconstruction with autologous right atrial tissue may obviate the need for mitral valve replacement in small children.
Systematic mediastinal lymphadenectomy or sampling is a critical component of lung cancer resection, ensuring accurate staging and potential therapeutic benefits. In this article, we will describe a standardized method for formal mediastinal lymphadenectomy which should provide a similar dissection outcome as described with open approaches. This method will also lends itself to reproducibility and facilitates teaching proper technique. We believe understanding and mastering techniques of systemic mediastinal lymphadenectomy will also help the procedure of sampling.
Acute Type A aortic dissections require urgent medical and surgical management but often are associated with high morbidity and mortality. Many surgical techniques exist for the repair or replacement of the dissected ascending aorta. We present a novel technique for Type A aortic dissections in which the dissected aortic wall is reconstructed with a polypropylene mesh and Bioglue, adding strength and integrity to the repair. This technique allows for a robust, flexible layer to be easily inserted between the adventitia and media, allowing for organic ingrowth and adding tensile strength. This technique provides for safe, reproducible, and durable repair for Type A aortic dissections.
Patients with extensive anterior mitral anular calcification or anterior mitral anular destruction from endocarditis with aortic and mitral valve disease often require reconstruction of the aortomitral curtain necessitating the Commando procedure. The Commando procedure has been shown to be a feasible option in these patients with outcomes comparable to those who underwent aortic and mitral valve replacement without aortomitral curtain reconstruction. However, anomalous coronary anatomy, particularly anomalous left circumflex artery from the right coronary artery in this setting can be technically challenging due to the artery’s course along the base of the noncoronary sinus of Valsalva which interferes with the debridement and transection of the anterior mitral anulus required for the Commando procedure. The objective of this paper is to describe our technique for Commando procedure in the setting of severe circumferential mitral anular calcification and anomalous coronary anatomy which requires coronary artery transection and bypass.
The 2 patch technique is the most standardized procedure for complete atrioventricular septal defect. However, patch insertion into the ventricular septal defect is sometimes difficult, especially in patients with Rastelli type A, and the technique itself does not address the deficiency of the left superior leaflet. We present the simplified patch augmentation technique of the left superior bridging leaflet as part of the 2 patch technique. This technique gives enough leaflet volume to establish the left atrioventricular valvular competency with minimal leaflet dehiscence risk.
Fontan patients previously thought not to be candidates for biventricular repair (BVR) because of complex anatomy are now being converted to biventricular circulations. However, older age at BVR is worrisome because of the abnormal pathophysiology that develops with years of single-ventricle circulation, especially restrictive systemic ventricular dysfunction. We report a 25-year-old Fontan patient with right atrial isomerism who underwent successful complex reconstruction with Fontan takedown. She was discharged home after two weeks and at 1 year postoperatively is doing well clinically with normal oxygen saturations.
In an atrial switch operation, the choice between the Senning and Mustard procedures depends on the patient’s anatomy and is at the surgeon’s discretion. The comparative study of these procedures has been controversial in terms of survival and reintervention rates. Previous evidence has shown that baffle-related reoperations are not uncommon after the Mustard procedure with an autologous pericardial patch. The primary advantage of the Mustard procedure with a Gore-Tex graft is that the graft's curvature maintains the shape and lumen of the baffle, thereby reducing the risk of kinking, especially immediately after surgery. In this report, we describe the Mustard procedure as part of double-switch operations for usual levocardia, approached from the right-sided atrium, and for dextrocardia, approached from the left-sided atrium.
Endoluminal vacuum therapy is a promising minimally invasive technique that promotes the healing of anastomotic leaks after esophagectomy. It offers an effective alternative to major surgical intervention. However, its widespread use is limited by the need for multiple sponge exchanges and the lack of commercially available systems. This paper presents a practical approach to creating a customized endoluminal vacuum therapy system, with the aim of improving accessibility and patient care.
Traditional methods of heart transplantation utilizing allografts from donors after circulatory death (DCD) involve 2 periods of ischemia and 2 ischemia reperfusion injuries (IRI). Both ischemia and IRI are associated with increased rates of primary graft dysfunction (PGD) as well as worsened short- and long-term survival. To minimize the ischemic insults - compounded by the subsequent reperfusion injuries - we have developed a beating heart implantation technique that obviates the need for a second cardioplegic arrest after ex vivo normothermic perfusion. By implanting the heart while beating and perfused with warm blood from the recipient cardiopulmonary bypass (CPB) circuit, this method mitigates ischemic and reperfusion injuries and has the potential to improve both short- and long-term outcomes by reducing the inflammatory response to these insults. This method is easily adoptable by experienced high volume heart transplant centers and has become our center’s standard of care for DCD heart transplantation. Herein, we describe the technical steps for beating heart implantation.
Mitral valve replacement (MVR) utilizing a Melody valve represents a viable alternative to mechanical valves in small children. Although the survival benefits of Melody-MVR over mechanical valves have been documented, there are unexpected reoperation rates associated with perivalvular leak or left ventricular outflow tract obstruction. To address these issues, we have modified the technique for implanting the Melody valve, minimizing manipulation of the stent and vein to prevent stent fracture and early valve deterioration. The double-secure sealing system of the Melody valve was developed to mitigate paravalvular leak; it consists of two purse-string sutures in addition to four interrupted annular cuff sutures that effectively seal the space between the stent and the annulus at the annulus level. Additionally, the sewing cuff of the pericardium is positioned below the annulus, facilitating tight surface-to-surface sealing of the subvalvular space. Another modification involves limiting the insertion of the Melody valve into the left ventricular cavity to prevent left ventricular outflow tract obstruction. The ideal candidate for Melody-MVR is a patient with irreparable valve disease and an annulus size of < 15 mm. However, the decision to select a Melody valve in cases requiring a 16–19-mm mechanical valve remains uncertain, warranting further study and exploration.
Background: Complete atrioventricular septal defect repair demands a balance of technical precision, anatomical respect, and surgical judgment. Despite advances, intraoperative variability and limited tactile guidance contribute to inconsistent outcomes.Methods: This article outlines a refined, narrative-guided 2-patch technique for complete AVSD repair, as practiced at our institution since 2020. Key principles include preserving leaflet mobility, respecting 3-dimensional valve curvature, and tailoring patch geometry to patient anatomy.Results: Since 2020, we performed 63 two-patch repairs. Operative mortality was 1.59%. Median postoperative length of stay among discharged patients was 10 days. Readmissions occurred in 12.7%, and reoperations in 6.3% of patients.Conclusions: Our approach emphasizes tactile feedback, valve-centric technique, and surgical humility. This article offers a reproducible, insight-driven strategy for achieving reliable results in AVSD repair.
Isolated right pulmonary artery that comes forms the residual patent ductus arteriosus is rare. Multiple techniques have been described to anastomose the right pulmonary artery to the main pulmonary artery. Herein we detail our technique of reconstruction using pulmonary artery flap and autologous pericardium.
Biventricular repair following hybrid palliation offers a refined approach for patients with borderline hypoplastic left heart structures, balancing early-stage palliation with deferred surgical decision-making. This manuscript outlines the operative strategies for achieving biventricular repair posthybrid palliation, detailing techniques such as aortic arch reconstruction, ventricular septal defect closure, and advanced procedures like the Ross-Konno and Yasui operations. Patient selection criteria, perfusion strategies, and technical considerations are emphasized to optimize outcomes. By leveraging the hybrid approach to enable staged physiological adaptation, biventricular repair expands therapeutic possibilities for select patients, improving long-term survival and functional outcomes.
Catheter-based thoracostomy using “pigtail catheters” has become a ubiquitous procedure for the management of pleural effusion or pneumothorax in many patient populations. Despite their widespread use, these small-bore catheters carry potential risks of significant morbidity and mortality, including intrathoracic vascular injury, parenchymal lung injury, and intra-abdominal placement. Moreover, malpositioned pigtail catheters are a notable cause of delayed care, increased cost, and frustration for patients and providers. Careful technique and understanding of the nuances in pigtail catheter placement can mitigate these complications and provide a roadmap for effective drainage.
