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PubMed1993

Disconnection of the ventilatory system does not prevent pleural lesions during sternotomy.

In previous studies pleurotomy has seldom been reported as a complication of sternotomy and, therefore, the incidence is unknown. Factors increasing or decreasing the risk of pleurotomy also have not been studied properly. In a prospective, randomized trial, performed during 14 consecutive months from 1988 until 1989, the incidence of pleurotomy and its possible risk factors were studied in 712 patients undergoing median sternotomy for cardiac and mediastinal procedures. The overall incidence of pleurotomy was 14.7%. Chronic obstructive pulmonary disease, the use of positive end-expiratory pressure, and continuation or discontinuation of the ventilatory system did not affect the incidence. A surgeon-related risk factor could be significantly identified (P < 0.001). In conclusion, disconnection of the ventilatory system during sternotomy has been shown to have no influence on the pleurotomy rate and its continued use is no longer valid.

Aged↗

PubMed2006

Cavo-atrial tumor resection under total circulatory arrest without a sternotomy.

Surgical management of intracardiac tumors arising in the inferior vena cava often requires total circulatory arrest for safe and adequate resection. Total circulatory arrest has traditionally been accomplished by accessing the great vessels through a sternotomy. Combination of a sternotomy and a large abdominal incision results in excellent exposure but also creates the potential for significant morbidity. We report here the resection of cavoatrial tumors by achieving total circulatory arrest through femoral arterial and venous cannulation without requiring a sternotomy. This minimal-access total circulatory approach has the potential to greatly diminish morbidity when managing tumors of the inferior vena cava.

Adult↗

PubMed2006

Clinical outcomes of noninfectious sternal dehiscence after median sternotomy.

BACKGROUND: Infectious complications of median sternotomy carry significant morbidity and mortality. However, the outcomes of noninfectious sternal dehiscence have not been addressed. We have identified the preoperative characteristics, postoperative complications, and long-term functional outcomes of patients after reoperation for noninfectious sternal dehiscence and compared these patients with a control group to determine risk factors for dehiscence. METHODS: Retrospective review of the cardiac surgery database identified 48 patients with noninfectious sternal dehiscence in a group of 12,380 median sternotomies between 1994 and 2004. The review included diagnosis, demographics, concomitant medical conditions, and surgical outcomes. Functional outcomes were assessed using the Short Form-12 questionnaire. One hundred fifty-six median sternotomy patients served as controls. Follow-up was 97.9% (47 of 48 patients) complete, for a total of 150.1 patient-years. RESULTS: Mean age of patients at reoperation was 58.8 +/- 12.8 years, with a male to female ratio of 45:3. Multivariate analysis determined that New York Heart Association class IV, obesity, and chronic obstructive pulmonary disease were preoperative risk factors for sternal dehiscence. The incidence of sternal dehiscence was 0.39% at a mean interval between initial operation and reoperation of 5.4 months. At a mean interval of 3.9 months, 14.6% (7 of 48) of patients required additional sternal procedures. Infectious complications after reoperation occurred in 12.5% (6 of 48). Functional outcomes demonstrated that 72.2% (26 of 36) had no or mild limitation of physical activities, with 90.5% (38 of 42) reporting no or mild sternal pain at follow-up. CONCLUSIONS: Although patients undergoing surgical correction of noninfectious sternal dehiscence fare better than those with infectious complications, optimal sternal approximation during the initial procedure and sternal precautions during convalescence should be emphasized to prevent recurrent complications.

Adult↗

PubMed2006

Mitral valve repair robotic versus sternotomy.

OBJECTIVE: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. METHODS: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloplasty. RESULTS: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal invasive group due to a bleeder on the left atrial appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. CONCLUSIONS: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair.

Aged↗

PubMed2005

Subxiphoid incisional hernias after median sternotomy.

BACKGROUND: Subxiphoid hernias are difficult to repair. This study attempts to identify risk factors associated with incisional hernia formation after median sternotomy. STUDY DESIGN: A retrospective review was conducted on patients undergoing subxiphoid incisional hernia repair between 1995 and 2002. The study group was compared with a group undergoing similar cardiothoracic procedures as to body mass index (BMI), comorbidities, complications, tobacco use, length of stay, ICU stay, bypass time, transfusion requirements, and wound infections. Statistical analysis utilized Student's t-test, chi-square, and Kaplan-Meier analysis. RESULTS: A total of 117 subxiphoid hernias were repaired; 45 were used for comparison with a matched cohort of 79 patients. Average time between sternotomy and hernia repair was 24.3 months (+/-16.8) with 22 (49%) patients developing hernias within 2 years. Mean followup was 48 months. The study group differed significantly from the nonhernia group in age (56.6 +/- 13.0 versus 62.2 +/- 8.9, p = 0.01), mean length of stay (16.3 +/- 22.8 versus 10.2 +/- 6.7, p = 0.03), BMI (29.6 +/- 4.5 versus 27.2 +/- 4.5, p = 0.01), number of transplantation patients (10 versus 1, p = 0.0003), and presence of sternal wound infection (18% versus 3.9%, p = 0.02). Multivariate analysis revealed significance in regard to transfusion requirements (p = 0.015) and approached statistical significance with BMI (p = 0.058). Of the 45 patients undergoing hernia repair, 31(69%) had a mesh repair and 10 (32%) patients recurred. Six (43%) patients without a mesh repair recurred. Seventy-five percent of the patients with sternal wound infections developed recurrent hernias. CONCLUSIONS: Transfusion requirements, BMI, and sternal wound infections might be associated with subxiphoid hernias after median sternotomy. Sternal wound infection increases the risk of recurrent incisional hernia.

Age Factors↗

PubMed2001

Off-pump grafting of the main circumflex coronary artery in the atrioventricular groove via sternotomy.

BACKGROUND: We report our off-pump technique for grafting of the main circumflex coronary artery in the atrioventricular groove performed through a median sternotomy. METHODS: Six patients with significant proximal stenoses of the circumflex coronary presented with small obtuse marginal branches. In each case, three-vessel coronary artery disease was present requiring median sternotomy. Each patient underwent off-pump grafting of the main circumflex coronary artery in the atrioventricular groove. Hemodynamic indicators were recorded every 60 seconds. RESULTS: In all six cases, the main circumflex coronary artery was bypassed using off-pump techniques. There was no significant hemodynamic compromise during the procedure and all patients did well postoperatively. Follow-up stress echocardiography and angiography was obtained. CONCLUSIONS: Grafting of the main circumflex coronary artery in the atrioventricular groove can be successfully and safely performed off pump through a median sternotomy.

Cardiopulmonary Bypass↗

PubMed2002

Thymectomy by partial sternotomy for the treatment of myasthenia gravis.

BACKGROUND: Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus. METHODS: From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy. RESULTS: Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms. CONCLUSIONS: Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.

Adult↗

PubMed2003

Total arch replacement for thoracic aortic aneurysm via median sternotomy with or without left anterolateral thoracotomy.

BACKGROUND: Thoracic aneurysms involving the ascending aorta, arch, and descending aorta are usually approached in a series of operations. Here, we report our clinical experience with total arch replacement through a median sternotomy with or without left anterolateral thoracotomy, using a technique that preserves the anterior wall of the distal arch to avoid injuring the left recurrent and phrenic nerves. METHODS: Between March 1999 and February 2001, 32 consecutive patients underwent total arch replacement through a median sternotomy alone (median group, n = 23) or in combination with a left anterolateral thoracotomy (LAT group, n = 9). In all cases, antegrade hypothermic selective cerebral perfusion was used in conjunction with mild hypothermic visceral perfusion (cool head-warm body perfusion). RESULTS: There were no in-hospital deaths and two late deaths. One patient in the median group had permanent neurological dysfunction postoperatively. There were no significant differences between the two groups in bypass time, cardiac ischemic time, respiratory assist time, beginning peroral intake, hospital stay, or postoperative respiratory function. The distal anastomosis level was significantly lower in the LAT group (thoracic vertebra level 7.1 +/- 1.5 vs 5.6 +/- 0.5, p = 0.0015). CONCLUSIONS: Preservation of the anterior wall in the distal arch may decrease in-hospital mortality and perioperative neurological dysfunction after total arch replacement. Total arch replacement through a median sternotomy with left anterolateral thoracotomy allowed expeditious and extended replacement of the aorta without increasing postoperative respiratory complications.

Adult↗

PubMed2004

Superficial wound dehiscence after median sternotomy: surgical treatment versus secondary wound healing.

BACKGROUND: Superficial wound dehiscence after midline sternotomy is considered a minor complication in cardiac surgery, although it is quite frequent and requires prolonged medical treatment. It can be managed conventionally by topical treatment, with delayed secondary healing, or by surgical treatment and primary skin closure. We report the outcome of 96 patients who underwent conventional treatment, compared with a second group of 42 patients who underwent surgical treatment and direct closure. METHODS: From October 1999 to December 2002, 2400 consecutive patients underwent median sternotomy: 207 patients had sternal wound complications: 3 patients (0.125%) had mediastinitis, 66 patients (2.75%) had aseptic deep sternal wound dehiscence, and 138 patients (5.75%) had superficial wound dehiscence. The latter are the object of the present study; patients entered a protocol of skin wound care on an outpatient basis. The first 96 consecutive patients (group 1) required medications three times a week until complete healing. The last 42 patients (group 2) were treated by extensive surgical debridement of skin and subcutaneous tissue, direct closure of the superficial layers, and suture removal after 15 days. RESULTS: The two groups were comparable as to age, sex, and preoperative risk factors. The incidence of contaminated wounds was similar in the two groups (32 of 96 in group 1 and 11 of 42 in group 2; p = NS). The length of treatment was 29.7 days (range 2 to 144 days) for group 1 and 12.2 days (range 2 to 37 days) for group 2 (p < 0.0001). The mean number of medical treatments was 9.4 per patient in group 1 and 3.7 per patient in group 2 (p < 0.0001). CONCLUSIONS: Surgical debridement and primary closure of superficial surgical wound dehiscence after median sternotomy is a safe and valid treatment. Wound infection is not a contraindication to surgical treatment. Primary closure may contribute to reduce the risk for later infection. It also definitely contributes to decreasing healing time and strongly lessens patients' discomfort, diminishing hospital costs and hospital staff workload.

Aged↗

PubMed1986

Effect of pleurotomy on pulmonary function after median sternotomy.

To determine whether pleurotomy during median sternotomy worsens postoperative pulmonary function, patients whose pleurae remained intact (N = 7) were compared with those whose pleural spaces were entered during median sternotomy (N = 31). Thirty-eight adults performed spirometry and N2 washout to determine functional residual capacity preoperatively and 2, 24, 48, and 72 hours after extubation. Two mediastinal drainage tubes were placed in every patient; no pleural drainage tubes were inserted. Chest roentgenograms were performed preoperatively and 24 and 72 hours after extubation. Preoperatively, functional residual capacity, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC did not differ between groups. Postoperatively, in all patients developed a restrictive pulmonary defect, but mean functional residual capacity, FVC, FEV1 and FEV1/FVC did not differ between groups. In contrast to earlier reports, entering the pleural space did not worsen the restrictive pulmonary defect that results from median sternotomy when direct pleural drainage was avoided.

Adult↗

PubMed1984

Catastrophic hemorrhage during redo sternotomy.

This paper reviews the attitude of 131 surgeons to the performance of a second sternotomy incision and assesses 144 severe hemorrhages that occurred as the sternotomy was being done. Eighty-eight percent of the hemorrhages occurred in situations in which the pericardium had not been closed at the first operation. From these events and the present attitude of surgeons responding to our questionnaire, we offer advice on the management of second sternotomies and on the management of hemorrhage when it occurs.

Catastrophic Illness↗

PubMed1986

Median sternotomy as a standard approach for pulmonary resection.

Pulmonary resection was performed electively through a median sternotomy in 174 patients. The first 61 of these patients were compared with an equal number having pulmonary resection through a lateral thoracotomy. Both groups were similar in regard to sex, age, pathological condition, and type of resection. The patients undergoing median sternotomy had a shorter operative time and less postoperative pain, and were discharged from the hospital sooner than the patients having resection through a lateral thoracotomy. The cardinal technical essentials to expeditious pulmonary resection through a median sternotomy involve unilateral pulmonary ventilation with a double-lumen endotracheal tube, arterial pressure and gas monitoring, and proper lung packing and retraction. Two patients died, 1 of infection and 1 of bleeding; neither death was related to the incision. Certain pulmonary procedures are better performed through a lateral thoracotomy, and these include resection of a superior sulcus carcinoma, pulmonary resection with posterior chest wall extension, and left lower lobe resection in patients who demonstrate obesity, cardiomegaly, or an elevated diaphragm.

Adult↗

PubMed1998

Risks of repeat sternotomy in pediatric cardiac operations.

BACKGROUND: Repeat sternotomy has been associated with increased perioperative risks. METHODS: We reviewed 165 patients undergoing 192 repeat sternotomies between January 1985 and January 1997 (group 1) and a control group of 184 patients (group 2). The operations in group 1 were valve procedures in 94 patients, Fontan procedure in 46, ventricular septal defect closure in 10, pulmonary arterioplasty in 17, and others in 25; in group 2 ventricular or atrial septal defect closure in 120 patients, tetralogy of Fallot repair in 26, valve procedures in 16, bidirectional Glenn anastomosis in 7, repair of transposition of the great arteries in 7, pulmonary arterioplasty in 4, and others in 4. RESULTS: The hospital mortality was 2.6% in group 1 and 3.8% in group 2. Cardiac laceration occurred in 10 of 192 patients (5.2%), requiring emergent femorofemoral bypass in 6 patients. Two patients sustained an air embolism that was successfully treated with a hyperbaric chamber. Median total blood loss and requirements were not significantly different between the two groups. The length of stay in the intensive care unit and in the hospital were 4 days (range, 1 to 80 days) and 11 days (range, 1 to 135 days) in group 1, and 2 days (range, 1 to 87 days) and 7 days (range, 1 to 131 days) in group 2 (p < 0.02 and p < 0.002, respectively). The rate of complications was not significantly different in group 1 versus group 2. Overall survival was 97% (group 1) and 95% (group 2) at 120 months' follow-up (not significant). CONCLUSIONS: With careful surgical technique and judicious use of femorofemoral bypass, the risk of repeat sternotomy is minimized.

Adolescent↗

PubMed1999

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach.

BACKGROUND: Cardiopulmonary bypass and cardioplegic arrest result in known physiologic inflammatory, coagulopathic, and embolic states that may result in end-organ damage. Interest in off-pump complete coronary revascularization using sternotomy exposure is therefore increasing. METHODS: Using specific surgical and anesthetic techniques, we have been able to achieve total revascularization using off-pump coronary artery bypass grafting procedures (OP-CAB) through a sternotomy approach. Exposure techniques and local stabilization are tailored to individual vessels and cardiac regions. Vascular control is achieved with silicone-elastomer loops, occluders, and shunts. Poor ventricular function, advanced age, and other comorbid conditions, in and of themselves, were not considered contraindications to OP-CAB. Cardiomegaly or situations of small, intramyocardial, or heavily calcified vessels were relative contraindications to OP-CAB. RESULTS: Of 141 sternotomy OP-CAB cases, 132 (93.6%) were completely off-pump. The mean number of OP-CAB grafts per patient in the cases that were completely off-pump was 3.3 (range, 1 to 6). The 30-day operative mortality was 0%. There were four instances of intraoperative cardiac arrest, precipitated by vascular occlusion of the right coronary artery or manipulating a cardiomegalic heart. Advanced age (> or = 80 years) or profound ventricular dysfunction (ejection fraction < or = 0.25) was present in a considerable percentage of patients (10.6% and 9.9%, respectively). CONCLUSIONS: Off-pump coronary artery bypass grafting is successful for total revascularization in large numbers of patients. Anatomic factors, including cardiomegaly and small, intramyocardial, or heavily calcified vessels are possible contraindications to OP-CAB. Patients at highest risk for undergoing cardiopulmonary bypass, including those of advanced age and having ventricular dysfunction, are precisely the ones in whom OP-CAB may be the most useful.

Adult↗

PubMed2000

Postoperative recovery in children after minimum versus full-length sternotomy.

BACKGROUND: Minimal access incisions for pediatric cardiac surgery have been reported to hasten postoperative recovery. This prospective study compared recovery after a minimum versus full-length sternotomy for repair of atrial septal defects in children. METHODS: We studied 35 children undergoing atrial septal defect repair using a full-length sternotomy (n = 18) or ministernotomy (n = 17) according to the surgeon's preference. All children were managed according to an established clinical practice guideline. Intraoperative comparisons included patient demographics, bypass and cross-clamp times, and, as a measure of stress response, epinephrine, norepinephrine, and lactate levels at six time intervals throughout the surgical procedure. Postoperative comparisons included pain scores at 6, 12, and 24 hours, frequency of emesis, analgesic requirements, respiratory rate and gas exchange, and length of intensive care unit and total hospital stay. Nurse and parent assessment scores of overall recovery were constructed using visual analog and Likert scales. RESULTS: No significant differences between mini- versus full-length sternotomy were detected for the measured outcome variables. No adverse outcomes were detected. CONCLUSIONS: In this prospective study, a ministernotomy did not enhance postoperative recovery, and the primary advantage appears to be an improved cosmetic result.

Adolescent↗

PubMed2000

Is early tracheostomy safe in cardiac patients with median sternotomy incisions?

BACKGROUND: Tracheostomy after cardiac operation through a median sternotomy is believed to increase the risk of mediastinitis, leading to debate as to whether early tracheostomy is safe in these patients. METHODS: A record search of patients undergoing cardiac operation through median sternotomy was done. Day and duration of tracheostomy were correlated to day of positive bacteriological evidence and clinical outcome for the patient. The method of tracheostomy was also recorded. RESULTS: Of 174 cases, 4 patients had mediastinitis, 3 before tracheostomy was performed. Of these three patients, 2 survived and the third died of multiorgan failure 46 days after the procedure. The fourth patient, on immunosuppressive therapy for severe rheumatoid arthritis and pulmonary fibrosis, had tracheostomy performed at primary operation, developed fatal mediastinitis after 6 days, and died 18 days postoperatively of multiorgan failure. Of the tracheostomies performed, 24 (14%) were percutaneous, and 110 (63%) were achieved using standard surgical techniques (in 40 cases type was unrecorded). In 72 cases (41%), tracheostomy was performed on or before day 7, 11 (6%) being performed before 48 hours. Mortality occurred in 38 (22%). CONCLUSIONS: There is no demonstrable relationship between early tracheostomy and mediastinitis in median sternotomy patients.

Cardiac Surgical Procedures↗

PubMed1999

Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy.

OBJECTIVE: We developed techniques for partial upper hemisternotomy for reoperative aortic valve replacement and compared the results with those of reoperative aortic valve replacement by way of conventional full resternotomy. METHODS: We retrospectively analyzed data from 19 patients who underwent conventional full sternotomy and 20 patients who underwent partial hemisternotomy for isolated elective reoperative aortic valve replacements performed between November 1996 and September 1998. Univariable and multivariable analyses were used to document the differences between the groups. RESULTS: The 2 groups were similar with respect to age, sex, New York Heart Association functional class, valve pathologic characteristics, and numbers and types of previous operations. There were neither any operative deaths nor any postoperative valve-related morbidities in either group. There was 1 injury to a cardiac structure, which occurred in the conventional full sternotomy group. Univariable analysis documented that patients in the conventional full sternotomy group were significantly more likely to have at least 1000 mL blood loss during the first 24 hours after the operation (odds ratio 8.1, P =.02), were more likely to require transfusion of more than 5 units of packed red blood cell (odds ratio 3.6, P =.08), and were more likely to have a total operative duration longer than 5 hours (odds ratio 3.6, P =.08). In the multivariable analysis conventional full resternotomy remained a risk factor for greater blood loss (odds ratio 5.7, P =.06), greater transfusion requirement (odds ratio 2.4, P =.25), and longer total operative duration (odds ratio 7.7, P =.03). CONCLUSIONS: Partial upper hemisternotomy for reoperative aortic valve replacement avoids unnecessary lower mediastinal dissection, thereby reducing blood loss, transfusion needs, and total operative duration. These beneficial effects, which are accomplished without compromising the efficacy of the valve operation, make the partial upper hemisternotomy an excellent alternative to conventional full resternotomy for reoperative aortic valve replacement.

Adult↗

PubMed1999

Mechanical analysis of midline sternotomy wound closure.

OBJECTIVE: Unstable median sternotomy closure can lead to postoperative morbidity. This study tests the hypothesis that separation of the sternotomy site occurs when physiologic forces act on the closure. METHODS: Median sternotomy was performed in 4 human cadavers (2 male) and closed with 7 interrupted stainless steel wires. The chest wall was instrumented to apply 4 types of distracting force: (1) lateral, (2) anterior-posterior, (3) rostral-caudal, and (4) a simulated Valsalva force. Forces were applied in each direction and were limited to physiologic levels (< 400 N). Four sets of sonomicrometry crystals were placed equidistantly along the sternum to measure separation at the closure site. RESULTS: Sternal separation occurred as a result of the wires cutting through the bone. Less force was needed to achieve 2.0-mm distraction in the lateral direction (220 +/- 40 N) than in the anterior-posterior (263 +/- 74 N) and rostral-caudal (325 +/- 30 N) directions. More separation occurred at the lower end of the sternum than the upper. During lateral distraction, xiphoid and manubrial displacement averaged 1.85 +/- 0.14 and 0.35 +/- 0.12 mm, respectively. Anterior-posterior distraction caused 1.99 +/- 0.04-mm xiphoid displacement and 0.26 +/- 0.12-mm manubrial displacement. During a simulated Valsalva force, more separation occurred in the lateral (2.14 +/- 0.11 mm) than in the anterior-posterior (0.46 +/- 0.29 mm) or rostral-caudal (0.25 +/- 0.15 mm) directions. CONCLUSIONS: These data suggest that sternal dehiscence can occur under physiologic loads and that improved sternal stability may be readily achieved via mechanical reinforcement near the xiphoid. Closure techniques designed to minimize wire migration into the sternum should also be developed.

Bone Wires↗