Endoscopic Mitral Valve Surgery (eBook)

lt;!doctype html public "-//w3c//dtd html 4.0 transitional//en">

Ralf Krakor, Klinikum Dortmund, Germany.

Ralf Krakor, Klinikum Dortmund, Deutschland.

Contents 6
Preface 10
1 Introduction 12
1.1 General thoughts on endoscopic surgery 12
1.1.1 The philosophy 12
The ideas behind it 12
Complexity 13
Experience 13
Valve repair – frequency of valve replacements 14
1.1.2 The team 14
1.1.3 Holding out 15
1.2 How to start an endoscopic program 16
1.2.1 Starting conditions for endoscopic mitral valve surgery 17
1.2.2 Patient-related arguments 18
Prognosis 18
Need for blood transfusion 20
Wound-healing disturbances 20
Cosmetic reason 21
1.2.3 Hospital-related arguments 22
Marketing 22
Economic reasons 22
1.2.4 Patient selection 24
1.2.5 Teaching course 26
1.2.6 Starter kit for endoscopic mitral valve surgery 26
1.2.7 Overview 27
2 Anesthesiology and pain management 30
2.1 Intubation and ventilation 30
2.2 Pain management 30
3 Technical prerequisites 34
3.1 Cannulas and extracorporeal circulation 34
3.1.1 Arterial cannulas (retrograde perfusion) 34
3.1.2 Arterial cannulas (antegrade perfusion) 35
3.1.3 Venous cannulas 36
3.1.4 Extracorporeal circulation 39
3.2 Accessories 39
3.2.1 Soft-tissue retractor 39
3.2.2 Arms for videoscopic camera and atrial retractor 40
3.3 Instruments 41
3.3.1 Atrial hook 44
3.4 Sutures 44
4 Preparations 48
4.1 Arterial and venous cannulation 48
4.1.1 Femoral vessel cannulation after preparation 48
4.1.2 Direct cannulation of the ascending aorta 51
4.2 Mini-thoracotomy 54
4.3 Ports 58
4.4 Videoscopy 59
4.4.1 The wrinkle 60
4.4.2 The diameter 61
4.4.3 The monitor picture 61
4.4.4 Additional helpful details 61
4.5 Cardioplegia 62
4.5.1 Use of cardioplegia 62
4.5.2 Operations under fibrillation 66
4.6 Aortic clamping 67
4.6.1 Endoclamping 67
4.6.2 The Chitwood technique 68
4.6.3 Complications 70
5 Valve repair techniques 72
5.1 Quadrangular resection 72
5.1.1 Pathological anatomy 72
5.1.2 Theoretical remarks 73
5.1.3 Practical realization 73
Identifying the prolapse 73
Cutting out of the prolapse 74
Narrowing of the annulus 76
Closure of the gap 77
5.2 Triangular resection 79
5.2.1 Pathological anatomy 79
5.2.2 Theoretical remarks 80
5.2.3 Practical realization 80
Identifying the prolapse 80
Cutting out the prolapse 81
Narrowing of the annulus 81
Closure of the gap 82
5.3 Sliding technique 82
5.3.1 Pathological anatomy 82
5.3.2 Theoretical remarks 83
5.3.3 Practical realization 84
Identifying the diseased parts 84
Cutting out of diseased part(s) 85
Retiring the leaflet 87
Narrowing of the annulus 88
Sliding and refixation 88
5.4 Neochords - preformed loops 89
5.4.1 Pathological anatomy 90
5.4.2 Theoretical remarks 92
5.4.3 Practical realization 94
Identifying the diseased parts 94
Measurement of the chordae length 94
Implantation of preformed loops 96
5.5 Neochords – flexible length 96
5.5.1 Pathological anatomy 97
5.5.2 Theoretical remarks 97
5.5.3 Practical realization 98
Identifying the diseased parts 98
Measurement of the chorda length 98
Implantation of flexible chords 98
5.6 Artificial rings 102
5.6.1 Theoretical remarks 102
5.6.2 Implantation technique 103
5.6.3 Complications 105
5.7 Emergency exit 106
5.7.1 Theoretical remarks 106
5.7.2 Practical performing 107
6 Tips and tricks 110
6.1 Perfusion’s challenge 110
6.2 Diaphragm's obesity 111
6.3 View’s hurdles 112
6.4 Instruments’ versatility 114
6.5 The knot pusher’s independent existence 117
6.6 Managing bleeding 120
6.6.1 Bleeding of ascending aorta 120
6.6.2 Bleeding of the left atrial incision 121
6.6.3 Bleeding of the left atrial appendage 121
6.6.4 Injury of the right pulmonary main stem 121
6.6.5 Injury of the right mammary artery 122
6.6.6 Bleeding of the intercostal artery 122
7 Additional procedures 124
7.1 Left atrial ablation 124
7.1.1 Endocardial ablation 124
7.1.2 Epicardial ablation - pulmonary veins clamp technique 126
7.1.3 Epicardial ablation - box lesion with Cobra Adhere XL® 127
Technical background of Cobra Adhere XL® 128
Heat sink effect 129
Practical use of Cobra Adhere XL® 130
7.2 Management of the left atrial appendage 132
7.3 Tricuspid valve repair 136
7.3.1 Access to the tricuspid valve 137
7.3.2 Repair technique 139
7.4 Closure of the ASD 139
7.4.1 Technical considerations 140
7.4.2 Closure of the ASD 140
7.5 Excision of left atrial tumors 142
7.5.1 Theoretical remarks 142
7.5.2 Practical performing 143
Index 144