Vertical right axillary thoracotomy for a modified Warden procedure with a descending thoracic aortic homograft: Tips and pitfalls

The Warden procedure has been described for the repair of a partial anomalous pulmonary venous connection that is inserted high in the superior vena cava. One long-term concern remains, which is related to the narrowing of the superior vena caval anastomosis. In fully grown teenagers and adults, we have modified the procedure by using an interposition graft that consists of a descending thoracic aortic homograft. It usually matches the size of the superior vena cava and avoids the need for anticoagulation. We also insert the homograft into the free wall of the right atrium rather than into the atrial appendage. We present the technique in a 16-year-old girl through a vertical right axillary thoracotomy.

Inverted aortic bioprosthetic for mitral valve replacement with Ross procedure: case report

Background A 34-year-old gentleman presented with Staphylococcus salivarius infective endocarditis 13 years after aortic homograft and mitral valve repair for degenerative bicuspid aortic valve associated with rheumatic heart disease. The homograft had calcified, and the mitral repair had deteriorated with severe regurgitation. Multidisciplinary team decision to restore best quality of life was for re-do Ross procedure with bi-leaflet preserving mitral valve replacement with an inverted RESILIA aortic valve as the patient was fundamentally against lifelong anti-coagulation. Case presentation The aortic homograft was excised, and coronary arteries dissected out followed by harvesting of the pulmonary autograft. The mitral valve was accessed via a trans-septal approach. On examination, there was a restricted and thickened posterior mitral valve leaflet. An inverted 27-mm INSPIRIS RESILIA aortic bio-prosthesis was placed with mitral cusps preserved. The pulmonary autograft was implanted in an intra-annular position, and a 26-mm pulmonary homograft was used to replace the pulmonary valve. Echocardiogram at 4 weeks revealed preserved LV function and well-functioning prosthetic, autograft and homograft. Conclusion An inverted RESILIA valve, with its anti-structural valve deterioration properties, can be used in the mitral position with preservation of the mitral cusps to avoid anti-coagulation with the hope of reducing need for re-operation in line with patient wishes.

Repair of Bronchial Anastomosis Following Lung Transplantation

Background Bronchial anastomotic complications are reported in 2 to 18% of patients after lung transplantation. The majority of complications can be managed with bronchoscopic intervention. When extensive dehiscence is present, surgical intervention can be entertained. Materials and Methods Between March 1, 2006, and December 31, 2019, our program performed 244 lung transplantations. We conducted a retrospective review of our patient cohort and identified patients who suffered from significant anastomotic complications that required surgical interventions. Results Twenty-eight and 216 patients underwent single and bilateral lung transplantations, respectively. Eighteen patients developed airway complications (7.4%). The incidence of anastomotic complications was 5.2% (24 complications for a total of 460 bronchial anastomoses). Four patients were managed conservatively. The majority of the bronchial anastomotic complications were managed endoscopically (eight patients). Four patients with associated massive air leak underwent repair of the bronchial anastomosis and two patients were retransplanted because they developed severe distal airway stenosis. Conclusion Bronchial anastomotic complications are a major cause of morbidity in lung transplantation. The majority of cases can be managed bronchoscopically. In more severe cases associated with massive air leak or imminent massive hemoptysis from bronchopulmonary arterial fistula, surgical intervention is necessary. Aortic homograft interposition along with vascularized pedicle wrapping may be a viable option to re-establish airway continuity when tension-free bronchial anastomotic revision is not possible. In cases with smaller bronchial defects, primary repair with utilization of a vascularized flap can be effective as treatment option.

Aortic homograft for aortic valve replacement in patient with Alpha-Gal allergy

Allergy to Galactose-Alpha-1,3-Galactose is an allergy to mammalian proteins, that are present on the surface of standard bioprosthestic valves, and could result in catastrophic allergic reaction or may cause early deterioration of the bioprostheses. Aortic homograft is an acceptable alternative to standard prosthetic valves (biological and mechanical) to avoid a potential allergic manifestation and the need of definitive oral anticoagulation. We report the implantation of an aortic homograft in a patient with an aortic stenosis who present a documented Alpha-Gal allergy.