Introduction

Article Outline

• Aortic Root Enlargement in the Adult: Nicks Technique and the Manougian Technique
• The Warden Procedure Compared with Baffling for Sinus Venosus Atrial Septal Defect
• Treatment of Malignant Mesothelioma
• Copyright

The 2006 Spring edition of Operative Techniques in Thoracic and Cardiovascular Surgery once again presents controversial technical surgical topics in three of our subspecialties, adult and pediatric cardiac surgery and general thoracic surgery. The Associate Editors have chosen excellent individuals to defend their points of view in this point/counterpoint setting.

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Aortic Root Enlargement in the Adult: Nicks Technique and the Manougian Technique 

Should one place a small valve in this patient or enlarge the root? Should one alter one’s prosthesis selection? Should one use a mechanical valve rather than a bioprosthetic one for the sake of improved hemodynamics or even consider a stentless xenograft or homograft? Are “small valves in small patients” acceptable. Is patient–prosthesis mismatch a real or imagined problem? These and related questions are hotly debated in academia and drive product development for our colleagues in industry. Although one may debate the strengths and weaknesses of opposing arguments in the literature, surely all surgeons sense that the more complete is the relief of an aortic valve gradient the better. Is it logical to replace a stenotic native valve with a stenotic prosthesis?

The immediate trade-off for the surgeon and patient is the difference in risks associated with implantation of a small valve in a small root compared with root enlargement or root replacement. In this issue we focus on two straightforward techniques to address the former option. We are indebted to two surgeons comfortable with these procedures for presenting their own approaches patterned after the classic opposing techniques described by Nicks and Manougian.

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The Warden Procedure Compared with Baffling for Sinus Venosus Atrial Septal Defect 

The congenital topic in this issue addresses the controversy regarding the optimal method for dealing with the sinus venosus atrial septal defect associated with partial anomalous pulmonary venous connection. The traditional technique of simply placing a pericardial baffle within the superior vena cava becomes increasingly difficult as the anomalous vein joins the superior vena cava more cephalad. There is an increasing risk of obstruction either to systemic venous return or pulmonary venous return from the anomalous vein. Brian Duncan from the Cleveland Clinic illustrates the traditional baffling technique, whereas Bob Gustafson from Morgantown, Virginia illustrates the alternative method first described by Herb Warden from Morgantown. Both techniques clearly have their place in the armamentarium of all congenital surgeons. These articles will help surgeons define how and when they wish to apply these techniques in their practice.

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Treatment of Malignant Mesothelioma 

All pleural tumors present a unique surgical challenge. Because the pleura abuts lung, chest wall, pericardium, and diaphragm, the surgeon planning an operation on a pleural tumor must consider not only the removal of the tumor but also the maintenance of normal barrier and respiratory function. Malignant mesothelioma, with it propensity for local recurrence, presents an even greater challenge: One must balance control of the tumor and the patient’s postoperative functional capacity. In this issue, we present two approaches differing in both surgical technique and timing of adjuvant therapy.