Total Arch Replacement +Frozen elephant trunk Zone2~for Acute Aortic Dissection　skin to skin 158min скачать в хорошем качестве

Total Arch Replacement +Frozen elephant trunk Zone2~for Acute Aortic Dissection　skin to skin 158min

Total Arch Replacement +Frozen elephant trunk Zone2~for Acute Aortic Dissection　A case with severe vascular calcification This is a total arch replacement (TAR) using a frozen elephant trunk (FET) from Zone 2 for acute aortic dissection. The key point is the management of the third branch. We place 4-0 sutures circumferentially and use a tourniquet to prevent retraction. In cases with severe calcification, we frequently use interrupted sutures (2-0, 25 mm) to prevent bleeding. This is a fundamental skill that I strongly encourage you to master. Explanation up to circulatory arrest. 0:00 Skin incision;Even in obese patients, the sternum should be divided within one minute. By making the incision just to the right of the xiphoid process, the skin incision can be minimized.In addition, the RA cannula and the retrograde CP/TALV perfusion cannula can be inserted safely. 1:51Pericardial incision: The initial cut should be made at the thinnest area where neither the aorta nor the heart can be injured. Since releasing tamponade will raise the blood pressure, be sure to inform the anesthesiologist in advance. 4:54 After placing the arterial cannula in the femoral artery, a venous drainage cannula is inserted into the right atrium. When placing sutures on moving structures such as the right atrium or the aorta, it is important to remember to press the needle gently against the tissue and advance it in a parallel manner. This technique allows safe needle passage without causing tissue injury. 8:00 Retrograde CP cannulation: By tilting the venous drainage cannula toward the assistant’s side, the tip of the cannula pushes the IVC toward the operator’s side. This maneuver widens the coronary sinus (CS), making cannula insertion easier. The tip of the cannula should be directed toward the left atrial appendage and advanced beneath the Thebesian valve of the CS. 9:50 A trans-left atrial left ventricular perfusion cannula is inserted (21 Fr Ez Grade, Edwards). Insertion is facilitated by approaching through the right-sided left atrium. In patients with aortic dissection, the pulmonary veins are often narrow, creating a potential risk of pulmonary vein obstruction (PVO). Therefore, insertion via the left atrium is the key point. By bending the inner stylet of the perfusion cannula into an S-shape, insertion into the left ventricle becomes easier. Advancing the cannula approximately 10 cm(There is a marker marking.) is sufficient to reach the left ventricle. Excessive advancement may result in LV rupture, so caution is required. If premature ventricular contractions (PVCs) occur, withdraw the cannula about 1–2 cm. 14:50 By inserting a PA vent, left ventricular distension can be relieved. The perfusion pressure from the left ventricle should be maintained around the 60 mmHg range. If the flow is insufficient, increase the femoral arterial flow to provide support. 25:08 A cannula for retrograde cerebral perfusion is inserted into the SVC. 28:45 Circulatory arrest is initiated once the pharyngeal (tympanic) temperature falls below 25 °C and the rectal (bladder) temperature falls below 28 °C. Cerebral protection is achieved by retrograde cerebral perfusion followed by three-vessel selective cerebral perfusion. Myocardial protection is provided with retrograde cardioplegia; if cardiac arrest is not achieved, selective cardioplegia is additionally administered. 28:55 Once circulatory arrest is instituted,the vent placed in the pulmonary artery is removed and replaced with the left ventricular perfusion cannula, which is then used as an LV vent.This provides an improved operative field.