Preface

*Res ipsa loquitur*  (The thing speaks for itself) (*Cicero, Pro Milone, 53*)

It has indeed been a great privilege to be the Editor of the new book *Front Lines of Thoracic Surgery*, with the efficient assistance of the InTech technical team.

In this original and promising editorial format, the book collects the up-to-date contributions on some of the most debated topics in today's clinical practice of cardiac, aortic and general thoracic surgery and anesthesia, as viewed by authors personally involved in their evolution.

The strong and genuine enthusiasm of the authors was clearly perceptible in all their contributions, and I'm sure that will further stimulate the reader to understand their messages. Moreover, the strict adhesion of the authors' original observations and findings to the evidence base proved that facts are the best guarantee of their scientific value.

Unfortunately however, no matter how strong their rational theoretical basis and evidence may be, new ideas and hypothesis are not usually accepted as easily and as quickly as any author would expect. That is the case in science in general and in surgery in particular.

This is probably most related to "tradition", which is obviously widely recognized as the most important founding value of any culture. However, tradition is apparently resistant to innovations in different science fields in inverse proportion to the complexity of their own theoretical content.

This places surgery in an unfavorable position since, even though extensive theoretical and technological research precedes and justifies any surgical treatment, performance of any surgical act relies on very few, elementary, "mechanical" principles.

In considering the evolution of the vascular anastomosis technique, it is interesting to note that the famous Carrel "triangulation" original sketch still reported straight, not an atraumatic needle, similar to that in use then for gastrointestinal suture. That was in X Preface

fact the necessary scenario for "triangulation" to stand for a very significant technical advancement at that point in time. Nonetheless, in spite of its persisting fame, "triangulation" was made obsolete by the advent of curved and proportionally dimensioned needles as well as of many other technical refinements.

After a century-long path, apparently pulverizing the retaining force of "tradition", the extreme evolution of surgical technique has today reached man-driven robotic surgery, suggesting that the theoretically insurmountable limits other science fields have (like absolute zero for lowest temperature, or light speed for highest velocity) do not seem to have been yet identified in surgery!

However the new "thing" brought to the final surgical act by the complex, highly technologic and expensive robot apparatus is, essentially, at this point in time, the significantly increased precision of the surgical act resulting from the amplification of the surgeon's hand movement in relation to that transferred to the activated instrument in the operative field. Mini-access and magnified operative field view in fact were options already brought to clinical practice by video assisted, mini-invasive surgery.

All together these new technical modifications of the final surgical act are advantageous enough to justify the sacrifice, at least for selected surgical conditions, of the still unparalleled versatility of the direct hand movements in the operative field.

Sometimes in my work on vascular anastomosis devices, I thought that proposing innovations in this basic surgical ambit could be quite similar to trying to popularize the use of the fork and knife in China. The thorough analysis and explanation of the many details that provide that a fork and knife are a better and easier method of controlling food than chopsticks for anyone, independently from his own local tradition, is as ingenuous and almost stupid as it is ineffective.

In surgery however, it is just the full and clear understanding of the little technical "things", that can reveal the expected and very relevant final effects to the patient and thus can eventually urge someone to accept the difficult, monopolizing and often bitter, but always exciting, challenge of bringing it into clinical practice.

I'm grateful to Dr Giuseppe Rescigno, Division of Cardiac Surgery, Lancisi Hospital, Ancona for the review of Dr H. Hiroshi's Chapter on Off Pump CABG.

> **Dr. Stefano Nazari** Fondazione Alexis Carrel Milan, Italy

X Preface

surgery.

fact the necessary scenario for "triangulation" to stand for a very significant technical advancement at that point in time. Nonetheless, in spite of its persisting fame, "triangulation" was made obsolete by the advent of curved and proportionally

After a century-long path, apparently pulverizing the retaining force of "tradition", the extreme evolution of surgical technique has today reached man-driven robotic surgery, suggesting that the theoretically insurmountable limits other science fields have (like absolute zero for lowest temperature, or light speed for highest velocity) do

However the new "thing" brought to the final surgical act by the complex, highly technologic and expensive robot apparatus is, essentially, at this point in time, the significantly increased precision of the surgical act resulting from the amplification of the surgeon's hand movement in relation to that transferred to the activated instrument in the operative field. Mini-access and magnified operative field view in fact were options already brought to clinical practice by video assisted, mini-invasive

All together these new technical modifications of the final surgical act are advantageous enough to justify the sacrifice, at least for selected surgical conditions, of the still unparalleled versatility of the direct hand movements in the operative field.

Sometimes in my work on vascular anastomosis devices, I thought that proposing innovations in this basic surgical ambit could be quite similar to trying to popularize the use of the fork and knife in China. The thorough analysis and explanation of the many details that provide that a fork and knife are a better and easier method of controlling food than chopsticks for anyone, independently from his own local

In surgery however, it is just the full and clear understanding of the little technical "things", that can reveal the expected and very relevant final effects to the patient and thus can eventually urge someone to accept the difficult, monopolizing and often

I'm grateful to Dr Giuseppe Rescigno, Division of Cardiac Surgery, Lancisi Hospital,

**Dr. Stefano Nazari** Fondazione Alexis Carrel

Milan, Italy

tradition, is as ingenuous and almost stupid as it is ineffective.

bitter, but always exciting, challenge of bringing it into clinical practice.

Ancona for the review of Dr H. Hiroshi's Chapter on Off Pump CABG.

dimensioned needles as well as of many other technical refinements.

not seem to have been yet identified in surgery!

**Part 1** 

**Adult Cardiac Surgery** 

**Part 1** 

**Adult Cardiac Surgery** 

**1** 

**Mitral Valve Subvalvular Apparatus Repair with** 

Degenerative mitral valve (МV) disease is a common disorder affecting around 2% of the population (Enriquez-Sarano M et al., 2009). The most common ending in patients with degenerative valve disease is leaflet rolapsed due to elongation or rupture of the chordal apparatus, resulting in varying degrees of МV regurgitation due to leaflet malcoaptation during ventricular contraction. The emphasis of clinical decision-making in patients with degenerative disease centres around the severity of regurgitation and its impact on symptom status, ventricular function and dimension, the sequelae of systolic flow reversal such as atrial dilatation/fibrillation and secondary pulmonary hypertension (PH), and the risk of sudden death (1-4). Current standard of care for MV rolapsed with severe mitral regurgitation (MR) is surgical MV repair (Adams et al., 2010). Implantation of neo-chordae with the use of expanded polytetrafluoroethylene (ePTFE) sutures (Gore Associates, Flagstaff, AZ, USA) has since its introduction into clinical practice by Frater et al. proven to be a valuable technique for contemporary MV repair. Chordal replacement enables preservation of native valve anatomy, physiological leaflet motion and creation of large mitral orifice area. Furthermore, it has contributed to the reparability independent of valve complexity (Seeburger et al., 2007).

Historically, the mitral valve is described as composed of the leaflets, chordae, and papillary muscles. However, the mitral valve structurally and functionally is part of the left ventricle and intimately associated with the atrium and fibrous skeleton of the heart. Thus, alterations to the fibrous skeleton and ventricular and atrial muscle contribute to and affect valvular

The leaflets are the valve component that creates the division between the atrium and ventricle. There are two distinct leaflets: the anterior or aortic and posterior or mural. The anterior leaflet is usually comprised of a single trapezoidal-shaped unit. The posterior leaflet is punctuated with multiple slits and clefts that define usually three, but up to six, distinct scallops (Fig. 1). The anterior and posterior leaflets are separated at the commissures but there is usually some continuity of the valve tissue close to the annulus. Further, if one looks

**1. Introduction** 

function.

**2.1 Leaflets** 

**2. Functional anatomy of the mitral valve** 

*Department of Adult Cardiac Surgery, Regional Clinic Hospital #1, Krasnodar,* 

**Artificial Neochords Application** 

Sergey Y. Boldyrev, Kirill O. Barbukhatty, Olga A. Rossokha and Vladimir A. Porhanov

*Kuban State Medical University, Krasnodar,* 

 *Russian Federation* 
