Introduction

Article Outline

• Mitral Valve Repair: Preservation Versus Triangular Resection
• Coarctation: Extended End-to-End Anastomosis or Reverse Subclavian Aortoplasty
• Thymectomy: Transcervical versus Transsternal
• Copyright

The Fall issue of Operative Techniques in Thoracic and Cardiovascular Surgery again compares two different techniques for the same lesion in adult, pediatric, and general cardiac surgery. The point–counterpoint or debate format in thoracic and cardiac surgery continues to be an increasingly popular educational tool, as the following sections illustrate.

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Mitral Valve Repair: Preservation Versus Triangular Resection 

Mitral valve repair has risen to the status of “standard of care” for most degenerative, regurgitant pathologic conditions. Carpentier’s development of teachable, reproducible techniques must be credited a large measure of this success and are applicable in the majority of cases. There are, however, other approaches worthy of note with which the versatile mitral surgeon should become familiar. With a strong foundation in Carpentier’s techniques, Dr Patrick Perier proposes an alternative approach to the prolapsing posterior leaflet: repair rather than resection. Interest in this approach seems to be growing among surgeons, and one can anticipate publication of large clinical series of the same in the future. This technique is also particularly useful in special circumstances, such as the heavily calcified mitral annulus, even for those surgeons otherwise committed to the Carpentier techniques. Equally at variance with the more commonly accepted techniques but contrasting with Dr Perier’s is Dr Thomas Orszulak’s triangular resection with universal annuloplasty. Derived from Dr Dwight McGoon’s original technique of triangular plication, Dr Orszulak’s approach is simple and straightforward. He and his colleagues have applied it with success over many years. We believe that the reader practicing mitral valve repair will find instances in which familiarity with both of these approaches will be useful.

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Coarctation: Extended End-to-End Anastomosis or Reverse Subclavian Aortoplasty 

The congenital topic for this issue focuses on coarctation repair. Coarctation continues to stimulate many controversies including the role of balloon angioplasty and stenting for the native coarctation. It is, however, generally accepted that if a coarctation is associated with hypoplasia of the distal aortic arch, then a surgical approach is necessary. The alternative approaches that have been applied for the management of the hypoplastic arch in association with coarctation are the more traditional approach of resection and extended end-to-end anastomosis versus the less conventional reverse subclavian aortoplasty. Drs Victor Tsang and S. Kaushal from The Great Ormond Street Hospital in London have illustrated their technique for the extended anastomosis approach in which the proximal descending aorta is brought up to the level of the proximal aortic arch. Our associate editor, Richard Jonas, has illustrated his approach to the reverse subclavian aortoplasty technique. The reader is likely to find both of these techniques to be helpful depending on specific patient characteristics.

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Thymectomy: Transcervical versus Transsternal 

The controversy surrounding the surgical approach to the thymus gland is a result of our poor understanding of the function of the thymus gland and the natural history of thymomas. The perturbed thymus gland appears to participate in the pathophysiology of a number of autoimmune and parathymic syndromes. The most common parathymic syndrome is myasthenia gravis. The muscle weakness associated with myasthenia gravis has led to interest in minimally invasive techniques including the transcervical thymectomy described by Drs de Perrot and Keshavjee. The unpredictable natural history of thymomas is illustrated by the recurrences and metastases noted in all large series irrespective of the initial stage of the tumor. Because of this unpredictability, many surgeons prefer a more radical transsternal thymectomy. The transsternal thymectomy described by Dr David Mason provides an opportunity to assess invasion as well as remove almost all ectopic thymic tissue. Both procedures may find useful application in the treatment of thymic disease.