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PubMed1995

Urgent heart transplantation in patients with previous sternotomies. Cardiac Transplant Team.

Critically ill patient status and prior sternotomy have separately been associated with increased risk of mortality and morbidity after heart transplantation. Consequently, the justification of assigning urgent priority for transplantation to critically ill patients with prior sternotomy may be arguable. The authors therefore undertook a retrospective analysis to evaluate the outcome of urgent and elective heart transplantation in 64 patients who had undergone one to four previous sternotomies. Patients in group 1 (n = 23) were critically ill and underwent urgent heart transplantation. Group 2 (n = 41) consisted of more stable patients who received heart transplantation as an elective procedure. Intravenous inotropes or mechanical circulatory support were required by all patients in group 1 but by none in group 2. The mortality rate within 30 days post-transplant was higher in group 1 than in group 2 (22% versus 10%), though the difference was not statistically significant. The 1-year actuarial allograft survival was similar between the two groups (72% versus 74%). In addition, there was no significant difference between groups 1 and 2 in the incidence of postoperative coagulopathy (57% versus 42%), re-exploration (13% versus 15%), early infections (57% versus 49%), renal failure (17% versus 10%) or rejection episodes in the first 3 months (65% versus 78%). The authors' findings suggest that despite higher operative mortality in critically ill patients with previous sternotomies, the intermediate-term outcome of heart transplantation in these patients is similar to that in more stable patients. Critically ill patients with prior sternotomies should therefore continue to be considered for urgent heart transplantation.

Cause of Death↗

PubMed2005

Minimally invasive surgery for cardiac myxomas using an upper hemi-sternotomy and biatrial septal approach.

BACKGROUND: Minimally invasive surgery is pervading all fields of surgery with the principal benefits being: reduced pain, smaller incision, faster recovery, shorter hospital stay and reduced cost. Cardiac surgery is no different. Cardiac myxoma morbidity and mortality depends on early diagnosis, adequate exposure, complete resection, minimal manipulation and unifocal presence. We reviewed our cases of cardiac myxoma excised via an upper hemi-sternotomy with a biatrial septal cardiac approach, to demonstrate this technique as a valid alternative to a full-length median sternotomy. METHODS: From April 1997 to March 1999, one surgeon excised two cardiac myxomas via this minimal technique. Upper hemi-sternotomy was midline without transverse sternal transection. Standard aortobicaval cardiopulmonary bypass and myocardial protection were established with complete tumour excision via a biatrial septal approach commenced in the left atrial dome and extended to the right atrial appendage. RESULTS: Inpatient care was prolonged with cardiorespiratory morbidity a consequence of preoperative co-morbidities. Neither patient required return to theatre and hospital mortality was nil. Patients demonstrated reduced sternal wound pain, reduced length of incision, excellent healing and improvement in New York Heart Association functional class with no evidence of recurrence. CONCLUSIONS: Most proposed benefits of minimally invasive surgery were demonstrated in cardiac myxoma application without significant compromise to patient care and recovery using upper hemi-sternotomy and biatrial septal approach. Cardiac myxoma excision via upper hemi-sternotomy and biatrial septal approach can be achieved without compromise to patient care.

Aged, 80 and over↗

PubMed2003

Mediastinoscopy and mediastinotomy after cardiac surgery: are safety and efficacy affected by prior sternotomy?

BACKGROUND: The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown. METHODS: We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001. RESULTS: During this period 28 patients (25 male and 3 female; mean age, 63 +/- 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 +/- 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n = 22; left anterior mediastinotomy, n = 7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n = 6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n = 10; lymphoma, n = 3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n = 1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications. CONCLUSIONS: Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.

Adult↗

PubMed1998

Comparison of staged thoracoscopy and median sternotomy for lung volume reduction.

BACKGROUND: Lung volume reduction operations have proved beneficial for emphysematous patients, but questions remain about the role of a unilateral procedure. METHODS: Fifty patients were prospectively enrolled in a lung volume reduction surgery program for emphysema with staged unilateral video-assisted thoracoscopic procedures (VATS group). These patients were compared with 29 patients having bilateral lung volume reduction procedures by median sternotomy. RESULTS: The VATS group was slightly older and had shorter 6-minute walk distances, but otherwise the two groups were similar. Hospital stays were shorter for each unilateral VATS procedure, but the total of the two hospital stays was longer than the stay for the sternotomy group (21.1 versus 14.8 days). Complications were comparable, there were no in-hospital deaths, and there was significant difference in the 1-year mortality rate (VATS, 6% versus sternotomy, 13.8%; p = 0.137). Functional test results were comparable between the groups with improvements in percent predicted forced expiratory volume in 1 second (VATS, 41%, and sternotomy, 40%), 6-minute walk distances (VATS, 48%, and sternotomy, 26%), dyspnea scores, and acid base measurements. CONCLUSIONS: Staged lung volume reduction operations do not appear to offer any measurable advantages over a single hospitalization and bilateral lung volume reduction procedures.

Aged↗

PubMed1999

Computed tomography of the sternum and mediastinum after median sternotomy.

BACKGROUND: Computed tomography is used in our hospital to diagnose complications after median sternotomy, but its efficiency is unknown. Nor is the computed tomographic appearance of normal healing of a median sternotomy known. Computed tomography was evaluated for its ability to diagnose mediastinitis and sternal dehiscence, and a reference material of normally healing median sternotomies was created. METHODS: In a prospective study, 20 patients with a normally healing median sternotomy were examined 1 week, 1 month, 3 months, and 6 months after operation. In a retrospective study, 87 scans from 65 patients that were made because a postoperative complication was suspected were reviewed. RESULTS: In the prospective study, all patients had clinically uneventful healing. None of the computed tomographic scans showed radiologic signs of healing at 3 months. At 6 months, half of the patients had healed completely. In the retrospective study, 49 scans were performed on suspicion of infection; 7 of them indicated mediastinitis, 2 were false-positive, while mediastinitis was present in a total of 16 of the scans. Thirty-eight scans were made because of sternal pain or suspected dehiscence; after 21 of the scans, recovery was uneventful, and in 11, the definite diagnosis was dehiscence or pseudarthrosis. CONCLUSIONS: Clinical healing of the sternotomy does not correlate with the computed tomographic image. Computed tomography is not a sensitive tool for diagnosing mediastinitis, and in patients with sternal pain, it adds little information.

Adult↗

PubMed2000

Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery.

OBJECTIVE: We developed techniques for 'inverted T' partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a 'minimally-invasive' approach, refines a number of technical aspects of this new approach and reports follow-up. METHODS: Between November 1996 and December 1999, we performed 34 AVRs or AVreRs after previous cardiac surgery by use of an 'inverted T' partial upper re-sternotomy. There were 25 (74%) men. Median ejection fraction was 54%, range 15-80%. Median age was 72, range 38-93. All were New York Heart Association functional class (NYHA) functional class II or III. Twenty-one (62%) had previous coronary artery bypass grafts (CABG) while 14 (41%) had previous valve surgery. Follow-up was 100% complete for a total of 593 patient months (median 19 months). RESULTS: Twenty-three (66%) underwent AVR of the native aortic valve while 11 (33%) underwent AVreR of a prosthetic aortic valve. There were no intraoperative or valve-related complications, and no conversion to full re-sternotomy was necessary. There were two (5.9%) operative deaths from an arrhythmia on postoperative day 4 and a large stroke during surgery, respectively. Twenty-four (75%) patients were free of major complications. There was no need for reoperation for bleeding and patients required a median of two units of packed red blood cells. Complications included new atrial fibrillation (n=3, 9%), pacemaker implantation (n=3, 9%) and deep sternal wound infection (n=2, 6%). Median lengths of stay in the intensive care unit (ICU) and in the hospital were 1 and 7 days, respectively. There was one (3%) late deep sternal wound infection and 2/32 (6%) late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively. CONCLUSIONS: Partial upper re-sternotomy presents a safe and effective alternative approach to AVR and AVreR after previous cardiac surgery, and is associated with low morbidity and mortality.

Adult↗

PubMed1998

Cardiac surgery by transxiphoid approach without sternotomy.

OBJECTIVE: In a attempt to avoid the potential drawbacks associated with sternotomy coupled with a desire for a smaller scar led us to investigate the transxiphoid approach without sternotomy. We present our preliminary experience and a comparison between the sternal and thoracic approaches. METHODS: From June 1996, at the Institut Cardiovasculaire Paris Sud, Massy, France (ICPS) and the Heart Institute, Sao Paulo, Brazil (HI) the transxiphoid approach was adopted for the correction of selected congenital cardiac defects. The xiphoid was resected through a 6 cm long vertical skin incision. With a special retractor the sternum was elevated cephalad and anteriorly. Closure of the defect was performed in the conventional manner. Twenty-six patients; 17 boys and 9 girls were entered into the study from representing 19 atrial septal defects (ASDs), 4 ventricular septal defects (VSDs) and 3 partial atrio ventricular septal defect (AVSDs). In addition at ICPS the transxiphoid approach for correction of ASD was compared to the thoracic and sternal approaches performed in the same period. RESULTS: Both the aortic cross clamp time as well as the duration of extracorporeal circulation were increased when compared to either standard sternotomy or thoracotomy approaches. There were no differences within the groups when comparing body surface area, amount of chest drainage or length of either ICU or hospital stay. However the patients in the transxiphoid group showed less pain and respiratory discomfort. CONCLUSION: Our initial experience with the transxiphoid approach without sternotomy confirms that it is a promising technique that can be considered an alternative to conventional sternotomy. The access is adequate for surgical procedures performed through a right atriotomy. The advantages include a better cosmetic scar, less surgical trauma, minimal respiratory discomfort and a potentially lower risk of infection. However cardiopulmonary bypass and cross clamp times are increased. There were no complications, and patient satisfaction was high.

Cardiac Surgical Procedures↗

PubMed1998

Minimally invasive aortic valve replacement via hemi-sternotomy: a preliminary report.

OBJECTIVE: Aortic valve replacement has been approached by standard sternotomy. We described a technique of aortic valve replacement where the aortic valve is exposed through a hemi-sternotomy. Good exposure is obtained for aortic valve surgery with standard aortic and right atrial cannulation to establish cardiopulmonary bypass (CPB). METHODS: From October 1996 to April 1997, 19 consecutive aortic valve replacements (AVR) via hemi-sternotomy were performed by one surgeon. The results were collected and analysed prospectively. Results are expressed as mean +/- standard deviation. Nineteen patients (13 male, 6 female) had AVR with this approach. Two cases were redo AVR. The mean age was 58+/-15 years. The New York Heart Association (NYHA) class was 2.8+/-0.7. RESULTS: Aortic cross clamp time was 54+/-13 min. One of six patients requiring defibrillation after reperfusion needed conversion to full sternotomy. Four patients were extubated at the conclusion of surgery. One patient died 4 h postoperatively from low cardiac output. All patients had normal valvular function demonstrated on postoperative transoesophageal echocardiography. There were no neurological events. CONCLUSIONS: Minimally invasive aortic valve replacement can be safely performed via hemi-sternotomy with standard equipment. Less surgical trauma to the sternum has the potential benefit of less pain and shorter intensive care and hospital stay.

Aortic Valve↗

PubMed2001

Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results.

BACKGROUND: This study compares intermediate-term outcomes of mitral valve reconstruction after either the standard sternotomy approach or the new minimally invasive approach. Although minimally invasive mitral valve operations appear to offer certain advantages, such as reduced postoperative discomfort and decreased postoperative recovery time, the intermediate-term functional and echocardiographic efficacy has not yet been documented. METHODS: From May 1996 to February 1999, 100 consecutive patients underwent primary mitral reconstruction through a minimally invasive right anterior thoracotomy and peripheral cardiopulmonary bypass and Port-Access technology (Heartport, Inc, Redwood City, Calif). Outcomes were compared with those for our previous 100 patients undergoing primary mitral repair who were operated on with the standard sternotomy approach. RESULTS: Although patients were similar in age, the patients undergoing the minimally invasive approach had a lower preoperative New York Heart Association classification (2.1 +/- 0.5 vs 2.6 +/- 0.6, P <.001). There was one (1.0%) hospital mortality with the sternotomy approach and no such case with the minimally invasive approach. Follow-up revealed that residual mitral insufficiency was similar between the minimally invasive and sternotomy approaches (0.79 +/- 0.06 vs 0.77 +/- 0.06, P =.89, 0- to 3-point scale); likewise, the cumulative freedom from reoperation was not significantly different (94.4% vs 96.8%, P =.38). Follow-up New York Heart Association functional class was significantly better in the patients undergoing the minimally invasive approach (1.5 +/- 0.05 vs 1.2 +/- 0.05, P <.01). CONCLUSIONS: These findings demonstrate comparable 1-year follow-up results after minimally invasive mitral valve reconstruction. Both echocardiographic results and New York Heart Association functional improvements were compatible with results achieved with the standard sternotomy approach. The minimally invasive approach for mitral valve reconstruction provides equally durable results with marked advantages for the patient and should be more widely adopted.

Cardiopulmonary Bypass↗

PubMed2000

Approaching the upper thoracic vertebrae without sternotomy or thoracotomy: a radiographic analysis with clinical application.

STUDY DESIGN: The distribution of the lowest vertebra tangential to the suprasternal notch and the lowest intervertebral disc visualized above the sternum was determined on magnetic resonance imaging (MRI) studies. The method is illustrated in seven patients undergoing upper thoracic spinal reconstruction to define a surgical approach without sternotomy or thoracotomy. OBJECTIVES: The relation of the sternal notch to thoracic vertebrae was examined by MRI to estimate the thoracic level approachable anteriorly without sternotomy. SUMMARY OF BACKGROUND DATA: Upper thoracic spine (T1-T4) visualization is considered difficult. The thoracic vertebrae that can be visualized anteriorly without sternotomy is unknown. METHODS: The vertebral level tangential to the suprasternal notch and the lowest intervertebral disc visualized in its entirety above the sternum was determined from 106 consecutive midsagittal cervicothoracic MRI studies. The method was evaluated in seven patients to illustrate application of a low suprasternal, lateral extracavitary, or transpedicular approach to performing upper thoracic reconstruction. RESULTS: The midportion of the T3 vertebra is often above the sternal notch, whereas the trajectory of the T1-T2 intervertebral disc is usually rostral to the sternum. All four patients with disease above the sternal notch on MRI underwent a low left suprasternal approach, whereas three others were treated with a lateral extracavitary or transpedicular approach. No patient worsened neurologically and all ambulated independently after surgery. CONCLUSIONS: Upper thoracic vertebrae can be exposed without sternotomy or thoracotomy by a low left suprasternal approach. Midsagittal cervicothoracic MRI can identify the thoracic vertebrae above the sternum, thereby determining whether a low suprasternal approach is feasible. Otherwise, a lateral extracavitary or transpedicular approach can be used to avoid sternotomy or thoracotomy.

Adult↗

PubMed2005

Scoliosis after median sternotomy in children with congenital heart disease.

STUDY DESIGN: A retrospective review of spinal deformity in patients with congenital heart disease surgically treated through a median sternotomy before the age of 8 years. Assessment was done on chest roentgenograms at skeletal maturity. OBJECTIVES: To determine if patients surgically treated through a median sternotomy present a higher prevalence of spinal deformity. SUMMARY OF BACKGROUND DATA: Congenital heart disease is associated with a higher prevalence of scoliosis. The etiology of scoliosis in this group of patients is unknown. Thoracotomy causes scoliosis, but median sternotomy has not been identified as a causal agent in these patients. METHODS: Chest roentgenograms were done after skeletal maturity in 128 patients to assess for the presence of a spinal deformity in the sagittal or coronal plane as a result of a median sternotomy for treatment of congenital heart disease before the age of 8 years in patients without any prior radiographic evidence of spinal or costal deformity before surgery. RESULTS: Forty-four (34.3%) of these patients had scoliosis greater than 10 degrees , 16 of them (12.5%) had curves greater than 20 degrees , and 33 (25.8%) had thoracic kyphosis lesser than 20 degrees . Patients operated before the age of 18 months had a significantly increased risk of developing scoliosis than those operated at a later age (odds ratio = 3.5; confidence interval = 1.3-9.6; P = 0.016). The presence of scoliosis was not related to the type of congenital heart disease. CONCLUSIONS: There is a high prevalence of scoliosis in patients with congenital heart disease surgically treated through a median sternotomy. The prevalence of scoliosis increases in patients operated at an earlier age.

Adolescent↗

PubMed2005

Staphylococcal post-sternotomy mediastinitis: five year audit.

BACKGROUND: The reported rate of post-sternotomy mediastinitis is between 0.8 and 2.3%, with up to 79% of cases caused by staphylococci. Mediastinitis is associated with significant morbidity and mortality. Obesity and diabetes are the only risk factors consistently identified. The aims of the present study were to determine the incidence and risk factors for staphylococci post-sternotomy mediastinitis and to audit its management. METHODS: The clinical records of patients with staphylococcal post-sternotomy mediastinitis between 1 January 1998 and 31 May 2003 were retrospectively reviewed. Information collected included patient demographics, comorbidities, operation type, microbiology findings, surgical and medical management, and outcome. Data collected on cases were compared with data collected in a prospective database of all patients undergoing cardiac surgery. RESULTS: The incidence of staphylococcal post-sternotomy mediastinitis was 1.2% (60 cases in 5176 median sternotomies). Staphylococcus aureus was isolated in 49 (82%) cases and coagulase-negative staphylococci in 11 (18%) cases. Eight (16%) S. aureus isolates were methicillin-resistant. Risk factors associated with mediastinitis were ethnicity, diabetes mellitus, emergency surgery, ejection fraction and length of preoperative hospital stay. In-hospital mortality was 15%. Eighteen per cent of cases were not cured by initial therapy. CONCLUSION: Staphylococcal mediastinitis is a serious complication with significant rates of relapse and mortality. This audit has lead to an evaluation of our clinical pathways to ensure that prevention and management of surgical site infection is optimized.

Adult↗

PubMed2006

Median sternotomy closure in dogs: a mechanical comparison of technique stability.

OBJECTIVE: To evaluate the mechanical properties of canine median sternotomy closure using double-loop cerclage compared with other commonly used cerclage sternotomy closure patterns. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Forty canine cadaveric sternal segments. METHODS: Median sternotomy-wire constructs were loaded to failure in a materials testing machine. Each construct was radiographed before and after testing. Specific wire configurations tested were: 2 single twist cerclage centered on the sternebrae, single twist figure of 8 pattern centered on the sternal synchondrosis, double twist figure of 8 pattern centered on the sternal synchondrosis, 2 double-loop cerclage centered on the sternebrae, and 1 double-loop cerclage centered on the sternal synchondrosis. Wire configurations were compared by craniocaudal translation of sternabrae on pre-test radiographs, and displacement during loading, and mode of failure, based on analysis of test video, and post-test radiographs. RESULTS: Double-loop cerclage did not provide superior mechanical stabilization of median sternotomy. Both figure of 8 patterns had the least displacement at higher loads. Two single twists that were centered on sternebrae were least able to prevent displacement at higher loads, caused the most craniocaudal translation before testing, and fractured more often at loads < or = 200 N compared with other configurations. CONCLUSION: Sternal wiring techniques stabilizing sternal synchondroses had the least displacement. Overall, figure of 8 cerclage appeared most suitable because they minimized displacement at high loads and facilitated accurate reduction during tensioning. CLINICAL RELEVANCE: In closing canine sternotomy, figure of 8 cerclage may be most suitable. Double-loop cerclage centered on the sternal synchondrosis should be avoided because of wire failure at high loads.

Animals↗

PubMed1998

Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution.

OBJECTIVES: To compare aortic valve replacement (AVR) using a minimally invasive approach through a transverse sternotomy with the established approach of median sternotomy. DESIGN: Retrospective, case-control study. PATIENTS: Fourteen high risk patients (median age 78, Parsonnet score of 18%) who underwent AVR performed through a minimally invasive transverse sternotomy were compared with a historical group of patients matched for age, sex, and Parsonnet score who underwent AVR performed through a median sternotomy by the same surgeon. OUTCOME MEASURES: Cross clamp time, total bypass time, intensive care stay, postoperative in-hospital stay, morbidity, and mortality. RESULTS: There were two deaths in the minimally invasive group and none in the control group (NS). The cross clamp and total bypass times were longer in the minimally invasive group (67 and 92 minutes v 46 and 66 minutes, p < 0.001). There was a higher incidence of re-exploration for bleeding (14% v 0%) and paravalvar leaks (21% v 0%) in the minimally invasive group but these differences were not significant. The minimally invasive group had a longer postoperative in-hospital stay (p = 0.025). The incidence of mortality or major morbidity was 43% (six of 14) in the minimally invasive group and 7% (one of 14) in the matched pairs (p = 0.013). CONCLUSIONS: AVR can be performed through a transverse sternotomy but the operation takes longer and there is an unacceptably high incidence of morbidity and mortality.

Aged↗

PubMed1998

Cervical rib and median sternotomy-related brachial plexopathies: a reassessment.

OBJECTIVE: The objective of this study was to identify electrodiagnostic and anatomic distinctions between true neurogenic thoracic outlet syndrome and median sternotomy-related brachial plexopathy, in reference to the pattern of abnormality of the medial antebrachial cutaneous sensory nerve conduction study (NCS) response. BACKGROUND: Neurogenic thoracic outlet syndrome and sternotomy-related brachial plexopathy are both lower trunk brachial plexopathies, but their clinical and electrodiagnostic presentations are distinct. The anatomic differences distinguishing these disorders from each other, and from other lower trunk brachial plexopathies, have not been defined. METHODS: We compared the medial antebrachial cutaneous sensory nerve action potential amplitude with the median motor, ulnar motor, and ulnar sensory NCS amplitudes in 10 patients with neurogenic thoracic outlet syndrome and in 14 patients with sternotomy-related brachial plexopathy. RESULTS: In the 10 patients with neurogenic thoracic outlet syndrome, the medial antebrachial cutaneous amplitude was most affected, followed in decreasing order of involvement by the median motor, ulnar sensory, and ulnar motor amplitudes. Conversely, in the 14 patients with sternotomy-related brachial plexopathy, the ulnar sensory and motor amplitudes were the most affected responses. Medial antebrachial cutaneous NCS changes closely paralleled median motor response changes. CONCLUSIONS: The medial antebrachial cutaneous sensory response is sensitive in the diagnosis of neurogenic thoracic outlet syndrome. Our data suggest that medial antebrachial cutaneous nerve fibers are closely associated anatomically at the T1 root level with median motor fibers innervating the thenar muscles. Neurogenic thoracic outlet syndrome shows predominant damage in the T1 distribution, whereas sternotomy-related brachial plexopathy shows predominant damage in the C8 distribution, suggesting that these lesions are localized at the level of the anterior primary rami of the cervical roots, and not in the lower trunk of the brachial plexus.

Adolescent↗

PubMed2001

Mini-sternotomy for the treatment of aortic valve lesions.

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous 1/4-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided more comfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.

Adult↗

PubMed1999

Influence of median sternotomy on the psychosomatic outcome in coronary artery single-vessel bypass grafting.

OBJECTIVES: New less invasive surgical techniques for the treatment of coronary artery single-vessel disease have been developed by either avoiding median sternotomy or cardiopulmonary bypass or both, however, until now no prospective randomized trial has been carried out to compare these techniques to the conventional approach with special respect to the psychosomatical effects. METHODS: In a prospective randomized trial four different surgical techniques were compared. Group 1: conventional technique (median sternotomy, cardiopulmonary bypass) in ten patients (eight male, two female, age 59.6 +/- 11.0 years); Group 2: off-pump coronary artery bypass with median sternotomy in nine patients (six male, three female, age 65.7 +/- 11.1 years); Group 3: lateral minithoracotomy and cardiopulmonary bypass in eight patients (five male, three female, age 62.3 +/- 9.9 years). Group 4: off-pump procedure and lateral minithoracotomy in nine patients (eight male, one female, age 63.8 +/- 11.3 years). All patients due to coronary artery single-vessel disease. The tests used for psychosomatic situation were post-traumatic stress disorders scale, pain behavior rating scale, pain visual analog scale, and 6' walking-distance. For detection of false results due to surgical technical failures 3-month follow-up was undertaken including echocardiography and coronary angiogram. RESULTS: There were no deaths or major complications. Operative time was longer in lateral minithoracotomy procedures, but intensive care unit stay and hospitalization were equal in all groups. Pain visual analog scale and pain behavior rating scale showed a peak on post-operative day 4 in median sternotomy procedures. Post-traumatic stress disorder scale revealed higher values on post-operative day 4 and equalizing with lateral minithoracotomy procedures 1 month post-operatively. Six-minutes walking distance on post-operative day 4 was longer in the group with lateral minithoracotomy. Three-month follow-up revealed patency of all grafts. CONCLUSIONS: Even if surgery is successful in all procedures, operative time is longer in lateral minithoracotomy procedures without compromising intensive care unit stay and hospital stay. More pain with multiple post-traumatic stress disorders is related to median sternotomy, and post-operative convalescence is superior for lateral minithoracotomy procedures.

Aged↗

PubMed1998

Endoscopic repeat sternotomy.

BACKGROUND: Repeat cardiac surgery represents eight to twenty five percent of cardiac surgical procedures. Catastrophic hemorrhage is a known complication of repeat sternotomy. A number of techniques have been described to reduce the incidence of injury to the heart and mediastinal structures during reoperation. This paper reports a new endoscopic technique to visualize and lyse the adhesions between the sternum and heart prior to repeat median sternotomy. METHODS: A unique substernal retractor and endoscopic visualization system was developed specifically to facilitate safe and rapid sternotomy in reoperative cardiac cases. Twenty-four patients underwent elective reoperation using the Endoscopic Redo Sternotomy Retractor and instrumentation. There were 5 patients with prior valve surgery and 19 patients with coronary bypass grafts in place. Retrosternal adhesions were divided with special endoscopic cautery or scissors after which a standard reciprocating saw was used to open the sternum without damage to underlying structures. RESULTS: The time required for endoscopic dissection of retrosternal adhesions ranged from 6 to 22 minutes. No injury to any cardiac structure or conduit occurred. CONCLUSIONS: The Endoscopic Redo Sternotomy Retractor provides excellent visualization of all retrosternal structures and adhesions allowing safe and meticulous dissection prior to sternal opening.

Equipment Design↗