Introduction

Article Outline

• Approaches to Pericardiectomy
• Anomalous Origin of a Coronary Artery from the Aorta
• Surgical Management of Subglottic Stenosis versus Surgical Repair of Iatrogenic Cervical Tracheal Stenosis
• Copyright

This issue of Operative Techniques in Thoracic and Cardiovascular Surgery describes alternative approaches to three significant disease processes in adult cardiac, congenital heart, and general thoracic surgery. We are fortunate to have excellent contributions from well-known groups with particular expertise in these areas and hope that the readers will enjoy and profit from their experience.

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Approaches to Pericardiectomy 

Pericardiectomy for inflammatory/constrictive disease is the subject of this section of Operative Techniques. Two highly-experienced groups present their approach to this often vexing diagnostic and therapeutic problem. Mauricio A. Villavicencio and his colleagues from the Mayo Clinic offer a thorough analysis of the anatomy and physiology of the pericardium, and discuss their approach to decision-making and operative therapy. This group favors the median sternotomy route, often supported by cardiopulmonary bypass, and emphasizes the importance of a complete pericardiectomy, to completely relieve symptoms, and prevent recurrence of the pericardial process. Ujjwal K. Chowdhury and colleagues, from the All India Institute of Medical Sciences in New Delhi, provide a discussion of the etiologic categories of pericarditis/constriction, including those encountered in third world populations, and explain how they decide which approach to employ. These authors list the advantages and disadvantages of the different surgical approaches, and describe how they match the incision to the particular etiology of the pericardial process. Theirs is a large experience, derived over many years, and offers the benefit of being a combined series of both median sternotomy and anterolateral thoracotomy.

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Anomalous Origin of a Coronary Artery from the Aorta 

A coronary artery arising from the wrong aortic sinus is a rare abnormality with a number of anatomic variations. Variants in which the coronary passes between the aorta and pulmonary artery have been associated with sudden death in young athletes. Although the exact level of this risk has been difficult to define, the implications for participation in sports have captured increased attention from the lay public and cardiologists, as well as surgeons. Historically, many patients have undergone coronary artery bypass grafting for this defect. As the significant limitations of bypass grafting have become apparent, an assortment of other surgical options has been described. The surgical approach needs to address variations in both the origin and course of the anomalous coronary. James Jaggers and Jay Pal from Duke University Medical Center describe coronary unroofing and creation of a neo-ostium, approaches applicable to intramural variants, and coronary reimplantation, applicable to extramural variants. Tom R. Karl from the University of California, San Francisco describes a repair strategy utilizing a pericardial coronary artery patch, and pulmonary artery translocation. These two articles provide excellent illustrations of the surgical options available for this group of coronary artery abnormalities.

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Surgical Management of Subglottic Stenosis versus Surgical Repair of Iatrogenic Cervical Tracheal Stenosis 

Tracheal resection and reconstruction remains a formidable operation for even the most experienced thoracic surgeon. In this issue of Operative Techniques, Nirmal K. Veeramachaneni and Bryan F. Meyers from Washington University describe their technique for tracheal resection and reconstruction for management of acquired strictures of the cervical trachea. In the companion article Cameron D. Wright from Massachusetts General Hospital outlines the surgical approach to subglottic stenosis. The anatomy of the recurrent laryngeal nerve and the posterior cricoid plate is emphasized in the article. Collectively, these two articles offer a superbly illustrated description of tracheal resection strategies and methods of reconstruction that will serve the reader well, regardless of the etiology of the tracheal pathology.