Commando procedure with posterior atrioventricular groove reconstruction.

This case presents a Commando procedure with posterior atrioventricular groove reconstruction in a patient after double-valve replacement performed in another hospital with a posterior atrioventricular groove patch due to mitral annular calcification for aortomitral Streptococcus agalactiae endocarditis. The patient was transferred to our institution on postoperative day 6 under femoro-axillary venoarterial extracorporeal membrane oxygenation with cardiogenic shock and pulmonary oedema due to patch dehiscence and severe periprosthetic mitral leak. To control pulmonary oedema and decrease myocardial tension, left atrial venting was performed in the intensive care unit through a redo sternotomy. After 24 hours, repeat reconstruction surgery was performed after improvement of pulmonary infiltrates and contractility. We alternate operative images with a porcine wet-lab model to facilitate understanding of this advanced reconstruction.

Cardiac retransplantation.

An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of durable mechanical circulation support, a small number of patients will be considered for a heart retransplant. In this video tutorial, we describe the strategy and technique for patients who have already received an orthotopic heart transplant and who undergo a cardiac retransplant with a modified bicaval anastomosis technique.

A heart transplant under temporary paracorporeal biventricular circulatory support.

Mechanical circulatory support as a strategy for a bridge to a heart transplant for patients with end-stage heart failure is increasing. A heart transplant following short-term support is a challenging procedure with many particularities. In this video tutorial, we present a 44-year-old patient who was bridged to a heart transplant with biventricular short-term paracorporeal support. The patient, who had dilated non-ischaemic cardiomyopathy, suffered an arrhythmic storm and was refractory to medical treatment and multiple ablation attempts. At the time the support was initiated, he was sarcopenic due to cardiac cachexia. He received a heart from a suitable donor after 10 days on mechanical circulatory support.

Comprehensive management of late mediastinitis involving an aortic Dacron graft.

We present a case of late mediastinitis following surgery for type A aortic dissection. After a thorough preoperative workup, the patient underwent a redo sternotomy, removal of all prosthetic material, and replacement of the aortic root with a homograft. The patient required venoarterial extracorporeal membrane oxygenation and delayed sternal closure for post-postoperative biventricular failure as well as prolonged antibiotic treatment. We present our institutional multidisciplinary approach for the management of such complex cases.

Venovenous extracorporeal life support circuit exchange: Tips and pitfalls.

Extracorporeal life support is a well-known therapy for acute respiratory failure. Its use has increased exponentially in recent years, even more since the beginning of the SARS-CoV-2 pandemic. Patients with COVID-19 may need long-term extracorporeal life support runs. They also suffer coagulation derangements that cause a prothrombotic state. Both situations may increase the need for exchanges of extracorporeal life support circuits. Extracorporeal life support circuit exchange should be performed as quickly and as safely as possible because patients may be completely dependent on it.

Postinfarction posterior ventricular septal defect repair: Infarct exclusion technique.

A 61-year-old man, an active smoker with associated chronic obstructive pulmonary disease on bronchodilator therapy, presented with acute inferior ST-elevation myocardial infarction. The right coronary artery was shown to be the infarct-related artery and was ultimately treated with a drug-eluting stent with an optimal angiographic result. Despite treatment, the patient continued to experience chest pain. Echocardiography showed an extensive posterior mid-ventricular septal defect. Given the scenario of an acute ventricular septal defect with impending hemodynamic repercussions, emergency surgery was pursued. After a median sternotomy and institution of cardiopulmonary bypass with bicaval cannulation, the inferior wall was exposed to assess the necrotic scar. After ventriculotomy, there was an irregular large septal defect with poorly defined margins. In this case, the posterior papillary muscle showed patchy areas of necrosis, requiring a mitral valve replacement. The ventricular septal defect was repaired using an oval-shaped bovine pericardial patch sutured with 3-0 polypropylene sutures, secured with Teflon pledgets, placed transmurally in healthy endocardium. The same patch was incorporated in the ventriculotomy closure.

Direct true lumen cannulation for type A aortic dissection (Samurai technique) in emergency scenarios.

Choosing the optimal arterial cannulation site in type A aortic dissection may be challenging. Aortic dissection is a dynamic condition that can change at any time. Thus all the alternatives available should be known by surgeons in order to adapt to the possible problems that may arise. In this video tutorial, we present a patient with acute type A aortic dissection who, after cardiopulmonary bypass with axillary arterial cannulation, developed a major complication: intraoperative malperfusion due to pressurization of the false lumen. The patient developed occlusion of the right coronary artery with electrocardiogram changes, inferior akinesia, and ventricular arrhythmias. Cerebral saturation was also significantly decreased. This scenario of acute malperfusion calls for immediate action.  We proceeded to switch the cardiopulmonary bypass configuration from axillary to direct true lumen cannulation. This technique, also known as the Samurai technique, is feasible in most cases and advantageous in this emergency situation, allowing prompt reestablishment of adequate perfusion of the true lumen . Some authors even advocate more widespread use of this technique because it may ensure antegrade perfusion while avoiding progression of the dissection flap and reduce the rate of the most common complications of other cannulation sites such as plexus injury during axillary cannulation or cerebral embolization through mobilization of thrombi or calcification from femoral retrograde perfusion. This technique is useful in cases of circumferential dissection and in patients with relative contraindications for peripheral cannulation such as morbid obesity or peripheral arterial occlusion by atherosclerosis or by the dissection itself.

Cone repair for Ebstein's anomaly and atrial fibrillation ablation in an adult patient.

We present a 52-year-old woman with Ebstein's anomaly not previously treated. In this subset of patients, there are no clear guidelines regarding the best surgical strategy for treating the tricuspid valve: replace it or repair it.  In this case, extensive repair of the tricuspid valve and the right ventricle is achieved using the cone repair technique popularized by Dr. José Pedro Da Silva. Because the patient also presented with symptomatic paroxysmal atrial fibrillation, a right atrial maze procedure combined with isolation of the pulmonary veins was performed using both radiofrequency and cryotherapy. At the last follow-up, 2 years after the repair, the patient is asymptomatic and maintains sinus rhythm. The last echocardiogram showed mild tricuspid regurgitation with normal right ventricular function.

Surgery for retrograde dissection and endoleak repair following endovascular repair of type B aortic dissection.

This video tutorial presents a case of repair of a delayed-onset retrograde type A dissection after TEVAR with a left carotid-subclavian bypass for acute type B dissection. One of our key challenges was problematic brain and spinal cord protection in a frail patient with distal dissection, and dissection involving an ectasic brachiocephalic trunk extending into the right carotid artery with a significantly increased risk of stroke and paraplegia.  We demonstrate the repair of the dissection using the frozen elephant trunk technique and we also present sequential brain and visceral perfusion diagrams.