Accepted Manuscript Useful Surgical Instruments in Resection of the Membrane or Muscle for Subaortic Stenosis Yuki Tanaka, MD, Takashi Miyamoto, MD, PhD, Yuji Naito, MD, PhD, Kagami Miyaji, MD, PhD PII:
S0022-5223(15)00517-6
DOI:
10.1016/j.jtcvs.2015.03.062
Reference:
YMTC 9493
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 17 March 2015 Accepted Date: 26 March 2015
Please cite this article as: Tanaka Y, Miyamoto T, Naito Y, Miyaji K, Useful Surgical Instruments in Resection of the Membrane or Muscle for Subaortic Stenosis, The Journal of Thoracic and Cardiovascular Surgery (2015), doi: 10.1016/j.jtcvs.2015.03.062. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Useful Surgical Instruments in Resection of the Membrane or Muscle for Subaortic
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Stenosis
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Running Head: Surgical Treatment of Subaortic Stenosis
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Yuki Tanaka, MD,1 Takashi Miyamoto, MD, PhD,1 Yuji Naito, MD, PhD,1 Kagami Miyaji, MD,
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PhD2
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1) Department of Cardiovascular Surgery, Gunma Children’s Medical Center, Shibukawa, Japan
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2) Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara,
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Japan
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Corresponding Author: Yuki Tanaka, MD
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Department of Pediatric Cardiac Surgery, Gunma Children’s Medical Center, 779 Shimohakoda,
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Hokkitsumati, Shibukawa, Gunma 377-8577, Japan
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Tel: +81-27-952-3559; Fax: +81-27-952 − -2045; E-mail: [email protected]
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Abstract
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Myotomy or myectomy for hypertrophic subaortic stenosis as well as membrane resection for
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discrete subaortic stenosis have been performed widely. We use custom-made surgical
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instruments for resecting membrane or muscle in these patients. These surgical instruments are
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made with consideration for the depth and angle to the target in the transaortic approach. We
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report the usefulness of these instruments based on a surgical case of subaortic stenosis.
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Myotomy or myectomy for hypertrophic subaortic stenosis (SAS) as well as membrane
26
resection for discrete SAS have been performed widely1, 2. Although some previous studies have
27
demonstrated problems, such as a high recurrence rate and postoperative aortic regurgitation
28
(AR), there is no alternative but to perform the operation in patients with a high pressure
29
gradient3, 4. Furthermore, it is difficult for individual cardiovascular surgeons to gain sufficient
30
experience outside of high-volume centers because of the low incidence of surgical cases. In
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order to perform this difficult surgical technique more easily, we use made-to-order surgical
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instruments for resection of the membrane or muscle in patients with SAS. These surgical
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instruments are custom-made for the depth and target angle in the transaortic approach. We
34
report their usefulness based on a sample surgical case of SAS.
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Clinical summary
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Data of instruments
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Here we describe the special features of surgical instruments for resection of the subaortic
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region (Figure 1). The scalpel has a total length of 22 cm and an angle of 140° at 3 cm from the
40
tip. It is used by attaching an edge to the tip. The scissor has a total length of 25 cm and an angle
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of 160° right in the middle. The retractors have a total length of 30 cm and an angle of 120° at 5
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cm from the tip with a groove.
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Case
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An 11-year-old girl was diagnosed as having discrete SAS with constrictive pericarditis.
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Although she did not have subjective symptoms due to severe mental retardation, we elected to
47
perform pericardiotomy with resection of the subaortic membrane owing to a high peak
48
instantaneous left ventricular outflow tract (LVOT) gradient of 80 mmHg. The operation was
49
performed by median sternotomy. After pericardiotomy, she was cooled to 32°C for cerebral
50
protection under cardiopulmonary bypass and subsequent cardiac arrest. After aortotomy, the
51
subaortic region was excellently exposed using angled retractors with a groove (Figure 2, A).
52
The obstructive fibrous membrane, which appeared on LVOT (Figure 2, B), and a part of septal
53
muscle were resected using a scalpel and scissors angled to enter the septal muscle at a shallow
54
angle (Figure 2, C and D). We confirmed passage of the diameter dilator (15 mm). After we
55
confirmed there was no aortic regurgitation and no injury of the aortic valve, incision of the
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aorta was closed. Postoperative peak instantaneous LVOT gradient was decreased, and this
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patient was discharged from the hospital on postoperative day 11.
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Discussion
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Although early surgical repair of SAS is associated with a significant recurrence risk and aortic
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regurgitation progression, surgical intervention is required in patients with a high LVOT
62
gradient2. LVOT obstruction repair by the transaortic approach is difficult due to the small
63
exposure and angle of approach. This approach, however, is necessary to avoid aortic valve
64
injury, ventricular septal perforation, and impulse conduction defect. Therefore, we sought
65
optimum instruments so as to decrease the risk of surgical complications. The surgical
66
instruments which we describe in this report are final-form adjusted several times. The area and
67
the depth of resection may vary in each case; however, we believe that this challenging surgical
68
procedure is performed more simply and safely with such devices. We hope for further
69
development of similar useful devices in cardiovascular surgery.
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References
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1. Morrow AG, Brockenbrough EC. Surgical treatment of idiopathic hypertrophic subaortic
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stenosis. Ann Surg. 1961;154:181.
82
2. Douville EC, Sade RM, Crawford FA Jr, Wiles HB. Subvalvular aortic stenosis: timing of
83
operation. Ann Thorac Surg. 1990;50:29-33.
84
3. Ashraf H, Cotroneo J, Dhar N, Gingell R, Roland M, Pieroni D, et al. Long-term results after
85
excision of fixed subaortic stenosis. J Thorac Cardiovasc Surg. 1985;90:864-71.
86
4. Hirata Y, Chen JM, Quaegebeur JM, Mosca RS. The role of enucleation with or without
87
septal myectomy for discrete subaortic stenosis. J Thorac Cardiovasc Surg. 200–9;137:1168-72.
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Figure Legends
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Figure 1
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Photograph of our made-to-order surgical instruments. From top to bottom, this figure shows a
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scalpel, angled a scissor, and retractors.
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Figure 2
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Intraoperative images. A, Exposure using angled retractors. B, Intraoperative endoscopy
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showing the subaortic membrane. C, An endoscopic image showing resection of the subaortic
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membrane used an angled scalpel (black arrow). D, Resection of the subaortic membrane using
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angled scissors (black arrow).
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S0022-5223(15)00517-6
DOI:
10.1016/j.jtcvs.2015.03.062
Reference:
YMTC 9493
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 17 March 2015 Accepted Date: 26 March 2015
Please cite this article as: Tanaka Y, Miyamoto T, Naito Y, Miyaji K, Useful Surgical Instruments in Resection of the Membrane or Muscle for Subaortic Stenosis, The Journal of Thoracic and Cardiovascular Surgery (2015), doi: 10.1016/j.jtcvs.2015.03.062. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Useful Surgical Instruments in Resection of the Membrane or Muscle for Subaortic
2
Stenosis
3
Running Head: Surgical Treatment of Subaortic Stenosis
4
RI PT
1
Yuki Tanaka, MD,1 Takashi Miyamoto, MD, PhD,1 Yuji Naito, MD, PhD,1 Kagami Miyaji, MD,
6
PhD2
7
1) Department of Cardiovascular Surgery, Gunma Children’s Medical Center, Shibukawa, Japan
8
2) Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara,
9
Japan
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SC
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TE D
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Corresponding Author: Yuki Tanaka, MD
12
Department of Pediatric Cardiac Surgery, Gunma Children’s Medical Center, 779 Shimohakoda,
13
Hokkitsumati, Shibukawa, Gunma 377-8577, Japan
14
Tel: +81-27-952-3559; Fax: +81-27-952 − -2045; E-mail: [email protected]
16
AC C
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EP
11
Text Word Count: 539 words
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1
ACCEPTED MANUSCRIPT
Abstract
19
Myotomy or myectomy for hypertrophic subaortic stenosis as well as membrane resection for
20
discrete subaortic stenosis have been performed widely. We use custom-made surgical
21
instruments for resecting membrane or muscle in these patients. These surgical instruments are
22
made with consideration for the depth and angle to the target in the transaortic approach. We
23
report the usefulness of these instruments based on a surgical case of subaortic stenosis.
SC
RI PT
18
AC C
EP
TE D
M AN U
24
2
ACCEPTED MANUSCRIPT
Myotomy or myectomy for hypertrophic subaortic stenosis (SAS) as well as membrane
26
resection for discrete SAS have been performed widely1, 2. Although some previous studies have
27
demonstrated problems, such as a high recurrence rate and postoperative aortic regurgitation
28
(AR), there is no alternative but to perform the operation in patients with a high pressure
29
gradient3, 4. Furthermore, it is difficult for individual cardiovascular surgeons to gain sufficient
30
experience outside of high-volume centers because of the low incidence of surgical cases. In
31
order to perform this difficult surgical technique more easily, we use made-to-order surgical
32
instruments for resection of the membrane or muscle in patients with SAS. These surgical
33
instruments are custom-made for the depth and target angle in the transaortic approach. We
34
report their usefulness based on a sample surgical case of SAS.
35
TE D
M AN U
SC
RI PT
25
Clinical summary
37
Data of instruments
38
Here we describe the special features of surgical instruments for resection of the subaortic
39
region (Figure 1). The scalpel has a total length of 22 cm and an angle of 140° at 3 cm from the
40
tip. It is used by attaching an edge to the tip. The scissor has a total length of 25 cm and an angle
41
of 160° right in the middle. The retractors have a total length of 30 cm and an angle of 120° at 5
42
cm from the tip with a groove.
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36
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43
Case
45
An 11-year-old girl was diagnosed as having discrete SAS with constrictive pericarditis.
46
Although she did not have subjective symptoms due to severe mental retardation, we elected to
47
perform pericardiotomy with resection of the subaortic membrane owing to a high peak
48
instantaneous left ventricular outflow tract (LVOT) gradient of 80 mmHg. The operation was
49
performed by median sternotomy. After pericardiotomy, she was cooled to 32°C for cerebral
50
protection under cardiopulmonary bypass and subsequent cardiac arrest. After aortotomy, the
51
subaortic region was excellently exposed using angled retractors with a groove (Figure 2, A).
52
The obstructive fibrous membrane, which appeared on LVOT (Figure 2, B), and a part of septal
53
muscle were resected using a scalpel and scissors angled to enter the septal muscle at a shallow
54
angle (Figure 2, C and D). We confirmed passage of the diameter dilator (15 mm). After we
55
confirmed there was no aortic regurgitation and no injury of the aortic valve, incision of the
56
aorta was closed. Postoperative peak instantaneous LVOT gradient was decreased, and this
57
patient was discharged from the hospital on postoperative day 11.
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Discussion
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Although early surgical repair of SAS is associated with a significant recurrence risk and aortic
4
ACCEPTED MANUSCRIPT
regurgitation progression, surgical intervention is required in patients with a high LVOT
62
gradient2. LVOT obstruction repair by the transaortic approach is difficult due to the small
63
exposure and angle of approach. This approach, however, is necessary to avoid aortic valve
64
injury, ventricular septal perforation, and impulse conduction defect. Therefore, we sought
65
optimum instruments so as to decrease the risk of surgical complications. The surgical
66
instruments which we describe in this report are final-form adjusted several times. The area and
67
the depth of resection may vary in each case; however, we believe that this challenging surgical
68
procedure is performed more simply and safely with such devices. We hope for further
69
development of similar useful devices in cardiovascular surgery.
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References
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1. Morrow AG, Brockenbrough EC. Surgical treatment of idiopathic hypertrophic subaortic
81
stenosis. Ann Surg. 1961;154:181.
82
2. Douville EC, Sade RM, Crawford FA Jr, Wiles HB. Subvalvular aortic stenosis: timing of
83
operation. Ann Thorac Surg. 1990;50:29-33.
84
3. Ashraf H, Cotroneo J, Dhar N, Gingell R, Roland M, Pieroni D, et al. Long-term results after
85
excision of fixed subaortic stenosis. J Thorac Cardiovasc Surg. 1985;90:864-71.
86
4. Hirata Y, Chen JM, Quaegebeur JM, Mosca RS. The role of enucleation with or without
87
septal myectomy for discrete subaortic stenosis. J Thorac Cardiovasc Surg. 200–9;137:1168-72.
M AN U
SC
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79
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Figure Legends
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Figure 1
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Photograph of our made-to-order surgical instruments. From top to bottom, this figure shows a
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97
scalpel, angled a scissor, and retractors.
SC
101
Figure 2
103
Intraoperative images. A, Exposure using angled retractors. B, Intraoperative endoscopy
104
showing the subaortic membrane. C, An endoscopic image showing resection of the subaortic
105
membrane used an angled scalpel (black arrow). D, Resection of the subaortic membrane using
106
angled scissors (black arrow).
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