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Ann Thorac Surg 1997;63:1180-1182
© 1997 The Society of Thoracic Surgeons

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How To Do It

Video-Assisted Resection of Hypertrophied and Fibrous Intraventricular Tissue

Division of Cardiothoracic Surgery, Kerckhoff-Clinic of Max-Planck-Institute, Bad Nauheim, Germany

Accepted for publication October 7, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
There is increasing interest in endoscopic techniques in cardiac surgery. However, use of the endoscope during open heart operations is still not routine. Cardioscopy has been used in patients with hypertrophied obstructive cardiomyopathy, asymmetric septal hypertrophy, or membranous subaortic stenosis. We demonstrate the resection of this pathologic tissue under direct visualization. With this technique we could increase the safety and accuracy of this surgical procedure. Beside this advantage, the entire operating room staff could follow the surgical intervention, which increases its educational side-effect.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
There is an increasing interest in video-assisted minimally invasive techniques in cardiac surgery. However, only a few publications deal with endoscopic procedures concerning intracardiac structures.

The first articles regarding diagnostic cardiac endoscopy described pericardioscopy to evaluate benign or malignant structures [1, 2]. Other publications reported closure of an open ductus Botalli or division of vascular rings in infants [3, 4]. More recently, some publications have described cardioscopic procedures dealing with intracardiac diagnostic or even therapeutic procedures [5].

This article deals with the technique of video-assisted resection of intraventricular hypertrophied myocardial or membranous tissue.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
By means of a median sternotomy, the heart is exposed, and cardiopulmonary bypass is established in a standard fashion. A vent is inserted through the left superior pulmonary vein into the left ventricle to provide a bloodless surgical field. The aorta is cross-clamped, and cold blood cardioplegia is infused by antegrade and retrograde route. The ascending aorta is opened. The cardioscope is inserted into aorta and passes the center of the aortic valve, in cases in which this does not have to be excised (Fig 1).

View larger version (73K): [in this window] [in a new window]   Fig 1. . Cardioscopic resection of hypertrophied septum. The cardioscope and the instruments are inserted into aorta, and they pass the center of the aortic valve.

The entire ventricular cavity is inspected, the hypertrophied myocardium or the membranous structure estimated, and the resection area defined. By means of elongated instruments, which are inserted parallel to the cardioscope, the fibrous (Fig 2) or muscular tissue (Fig 3) is resected.

View larger version (68K): [in this window] [in a new window]   Fig 2. . Resection of fibrous subaortic stenosis (green arrow). The fibrous tissue and the jet lesions on the septum are white.

View larger version (59K): [in this window] [in a new window]   Fig 3. . Resection of the hypertrophied muscle (green arrow) by means of a rongeur and a scalpel. The circumjacent structures such as the chordae (blue arrow) are clearly visualized. The nonresected hypertrophied septum with jet lesions is white.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

 
The use of cardioscopic techniques in cases of resection of intracardiac tissue shows several advantages compared with the conventional approach. Although the projection on the screen is only two-dimensional, the magnified and well-illuminated operating area facilitates the entire procedure. Now it is possible to resect tissue even deep in the ventricle with simultaneous visualization of neighboring structures such as the mitral valve, the papillary muscles, the chordae, or the septal myocardium. We assume that this technique allows thorough and safe resection of this pathologic tissue.

Other groups have tried to visualize intracardiac structures by means of intraoperative transesophageal echocardiography. This method was used to determine the extent of hypertrophied tissue before and after the operation [6]. However, transesophageal echocardiography does not allow the surgeon to control resection during operation. Furthermore, adjacent structures such as chordae of the mitral valve can hardly be seen.

We have used cardioscopy in different situations such as examination of the valve before reconstruction and after repair, assessment of ventricular septal defect, removal of foreign bodies, for diagnostic purposes, and for control of entry and reentry in aortic arch dissection. The procedure was carried out without complications in all cases and without a significant increase in cross-clamp time.

We conclude that cardioscopy is a supporting technique to clearly identify intracardiac structures, to control several surgical procedures, and to educate surgeons and operating room staff. Handling is easy and does not increase the operative risk. Different applications of cardioscopy will have to be investigated.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment References

 
Address reprint requests to Dr Bauer, Division of Cardiothoracic Surgery, Kerckhoff-Clinic of Max-Planck-Institute, D-61231 Bad Nauheim, Germany (e-mail: Erwin.P.Bauer{at}Kerckhoff.med.uni-giessen.de).

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. Little AG, Ferguson MK. Pericardioscopy as adjunct to pericardial window. Chest 1986;89:53–5.[Abstract/Free Full Text]
2. Mack MJ, Landreneau RJ, Hazelrigg SR, Acuff TE. Video thoracoscopic management of benign and malignant pericardial effusions. Chest 1993;103:390S–3S.
3. Burke RP, Rosenfeld HM, Wernovsky G, Jonas RA. Video-assisted thoracoscopic vascular ring division in infants and children. J Am Coll Cardiol 1995;25:943–7.[Abstract]
4. Laborde F, Noirhomme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105:278–80.[Abstract]
5. Legget ME, Shaw DP. Fiberoptic cardioscopy under cardiopulmonary bypass: potential for cardioscopic surgery? Ann Thorac Surg 1994;58:222–5.[Abstract]
6. Marwick TH, Stewart WJ, Lever HM, et al. Benefits of intraoperative echocardiography in the surgical management of hypertrophic cardiomyopathy. J Am Coll Cardiol 1992;20:1066–72.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Erwin P. Bauer Oliver T. Reuthebuch Matthias Roth Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bauer, E. P. Articles by Klövekorn, W.-P. Search for Related Content PubMed PubMed Citation Articles by Bauer, E. P. Articles by Klövekorn, W.-P.