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At least 19 recordsLinked to original sources

PubMed2006

Comparison of straight sternotomy and interlocking sternotomy in open heart surgery.

BACKGROUND AND OBJECTIVES: Stable sternal approximation is an important factor to avoid respiratory complications after open heart surgery. The present study is designed to compare interlocking sternotomy and straight sternotomy in terms of sternal stability, pain and respiratory function. METHODS: Sixty patients scheduled for open heart surgery underwent a standard midline sternotomy (n=30) or an interlocking sternotomy (n=30). The features assessed were pain on visual analogue scale during rest and during cough, peak expiratory flow rate and sternal instability. Evaluation was performed on the first, fourth post-operative days, on discharge and one month and three month follow up. RESULTS: Analysis of the peak expiratory flow rates, visual analogue ratings of pain intensity at rest and on coughing were carried out for each group only for those patients who completed the study. Postoperatively, in all patients there was significant reduction in peak expiratory flow rates. In the straight sternotomy group resting pain intensity was higher on discharge (2.6+/- 2 vs 1.6 +/- 2.3, P= 0.005). In the interlocking sternotomy group pain on coughing was significantly less than straight sternotomy group (median 0.5 vs 2.8, P=0.005) at 1 month follow up and at 3 months (median 0 vs 1.6, P=0.003). INTERPRETATION AND CONCLUSION: Interlocking sternotomy can be performed with good functional results and offers a less painful alternative to straight sternotomy.

Adolescent↗

PubMed2002

Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy.

BACKGROUND: the theoretical advantages of mini-invasive cardiac surgery are shorter hospitalisation, better surgical results and costs reduction. In November 1997 we started a non-coronary mini-invasive surgery program using a partial upper median sternotomy. This study has been conceived to retrospectively compare two groups of patients who underwent isolate aortic valve replacement using the conventional and the mini-invasive technique. MATERIAL AND METHODS: in Group A 100 patients (mean age 62+/-12 years; 58 male) underwent isolated aortic valve replacement through a partial upper median sternotomy. Group B was composed by the last 100 patients (mean age 63+/-8 years; 56 male) who underwent the same operation through a conventional median sternotomy. For both groups we recorded the ECC and ischaemic times, postoperative intubation time, total postoperative bleeding, intensive care unit length of stay and total hospitalisation time. Major and minor complications were reported. RESULTS: operating times, were significantly longer in Group A (p<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups. CONCLUSIONS: in our experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart for an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmethical result for the same given risk.

Aged↗

PubMed1988

Faulty sternotomy and complications after median sternotomy.

In 11 of 55 patients with complications of median sternotomy, a paramedian sternotomy has been detected by computed tomography or at reparative operation. The thin side of the sternum is easily broken by the closing wires, this being the cause of instability and probably dehiscence and consequent infection and osteomyelitis. Most of the 11 patients in this group had some other predisposing risk factors, such as obesity, prolonged aortic cross-clamp time, and prolonged respiratory assistance. We suggest that, if a paramedian sternotomy is diagnosed at the primary operation, special closure techniques should be undertaken. Each patient with early dehiscence of a median sternotomy should undergo a computed tomographic examination. If a paramedian sternotomy is proved, simple reclosure is inadvisable. Sternectomy and closure with muscle flaps are then indicated.

Humans↗

PubMed2005

The Women's Recovery from Sternotomy (WREST) study: design of a randomized trial of a novel undergarment for early use after sternotomy.

BACKGROUND: Clinicians who work with women poststernotomy often suggest that they wear a supportive brassiere to ameliorate pain, discomfort, and potential wound complications. There is no empirical evidence that supports this practice. METHODS: Despite methodological challenges, a clinical trial is currently underway to investigate the efficacy of early use of a novel undergarment after sternotomy. Women (N = 430) having first time sternotomy in 9 Canadian centers will be randomized to receive either the usual care of the institution or early use of a novel undergarment. Follow-up is planned over 12 postoperative weeks. Coprimary outcomes are pain, discomfort, and return to function. Wound healing is a secondary outcome. An economic evaluation substudy is also underway. CONCLUSIONS: The WREST Study is a unique ongoing trial examining the efficacy of a novel undergarment in reducing women's pain and enhancing their comfort and return to function. The findings of the trial and its economic substudy will enable health care providers to make rational evidence-based clinical decisions regarding women's early care after sternotomy.

Activities of Daily Living↗

PubMed2006

A randomized controlled trial of women's early use of a novel undergarment following sternotomy: the Women's Recovery from Sternotomy Trial (WREST).

BACKGROUND: Despite a lack of randomized trial evidence, clinicians often suggest that women use a brassiere to reduce poststernotomy pain and discomfort. We tested the effect of women's use of a special (compression) undergarment after sternotomy on pain, discomfort, and functional status. METHODS: Women (n = 481) having first-time sternotomy in 1 of 10 Canadian centers were randomized to receive the intervention or usual care. Pain and discomfort data (using numeric rating scales) were collected in person while participants were hospitalized. Thereafter, pain, discomfort, and functional status data (using Health Assessment Questionnaire) were collected by standardized telephone interview until 12 postoperative weeks. RESULTS: Overall, and until at least 6 weeks postoperatively, fewer women in the intervention than usual care group reported having incision and breast pain and discomfort. Breast pain scores were lower in the intervention than the usual care group at 2 weeks postoperatively (P = .04), and over time (OR 0.65 [95% CI 0.45-0.94], P = .02). For women discharged within 14 postoperative days, post hoc analyses revealed intervention group patients had a significantly reduced likelihood of breast pain (OR 0.46 [95% CI 0.32-0.66], P < .001) and breast discomfort (OR 0.62 [95% CI 0.44-0.86], P = .01) but not incision pain (OR 0.99 [95% CI 0.72-1.37], P = .95) or discomfort (OR 0.77 [95% CI 0.55-1.02], P = .06). There was no difference between groups in functional status. The effects were not influenced by age or brassiere size. CONCLUSIONS: Using a supportive undergarment during the early postoperative reduces breast pain. This finding is amplified and extends to include a reduction in breast discomfort, when women are discharged within 14 postoperative days.

Aged↗

PubMed1997

[Mediastinitis after sternotomy. Mortality and hospital length of stay. Groupe parisien détude des sternotomies].

The morbidity of deep sternal wound infections after sternotomy was assessed by a case-controlled study. The 41 cases were identified by a prospective enquiry over 4 months in 10 centres of cardiac surgery in the Paris region. The cases were compared with 41 non-infected controls, paired by centre, age, gender, ASA anaesthetic risk, stage of cardiac failure and type of surgery. The criteria of pairing were respected in 96% of cases. The mortality was 12% in the study population and 5% in the controls. Thirty-two of the 41 cases required reoperation for the sternal wound infection, usually to insert Redon drains after debridement of the wound. The total duration of the hospital stay was 53 days in the study cases and 30 days in controls, a median prolongation of the hospital stay of 23 days. The authors conclude that deep wound infection after sternotomy is responsible for almost doubling the duration of hospital stay. The economic consequences alone justify active research into the prevention of this complication.

Aged↗

PubMed2004

Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery.

BACKGROUND: The National Emphysema Treatment Trial, a randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema, included randomized and nonrandomized comparisons of the median sternotomy and video-assisted thoracoscopic approaches for lung volume reduction surgery. METHODS: Lung volume reduction surgery was performed by median sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6 centers randomized the approach to lung volume reduction surgery. Mortality, morbidity, functional status, and costs were assessed. RESULTS: In the nonrandomized comparison, 359 patients received lung volume reduction surgery by median sternotomy, and 152 patients received lung volume reduction surgery by video-assisted thoracoscopy. The 90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted thoracoscopy (P =.67). Overall mortality was 0.08 deaths per person-year for median sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy (video-assisted thoracoscopy-median sternotomy risk ratio, 1.18; P =.42). Complication rates were low and not statistically different for the 2 approaches. The median hospital length of stay was longer for median sternotomy than for video-assisted thoracoscopy (10 vs 9 days; P =.01). By 30 days after surgery, 70.5% of median sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living independently (P =.02). Functional outcomes were similar for median sternotomy and video-assisted thoracoscopy at 12 and 24 months. Costs for the operation and the associated hospital stay and costs in the 6 months after surgery were both less for video-assisted thoracoscopy than for median sternotomy (P <.01 in both cases). Similar results were noted for the randomized comparison. CONCLUSIONS: Morbidity and mortality were comparable after lung volume reduction surgery by video-assisted thoracoscopy or median sternotomy, as were functional results. The video-assisted thoracoscopic approach to lung volume reduction surgery allowed earlier recovery at a lower cost than median sternotomy.

Aged↗

PubMed2000

Manubrium-sparing median sternotomy as a uniform approach for cardiac operations.

We used a manubrium-sparing sternotomy to perform intracardiac operations on 26 patients between November 1997 and April 1998. We developed this less-invasive surgical technique as a uniform approach in order to reduce skin and skeletal trauma, while maintaining the advantages of the full median sternotomy, such as standard aortic and venous cannulations and use of both antegrade and retrograde cardioplegia. During the same period, 26 other patients with intracardiac lesions underwent operation through a standard full sternotomy. In the manubrium-sparing sternotomy group, there was no intraoperative complication or conversion to full median sternotomy. The average postoperative chest drainage was less in the manubrium-sparing sternotomy group (242.7+/-184.5 mL/24 hours, vs. 499.2+/-416.3 mL/24 hours; P<0.01). Two patients (77%) in the manubrium-sparing sternotomy group had superficial wound disruption, but 4 patients (15.4%) in the full sternotomy group had more severe wound infection, and 1 required myoplasty because of deep wound infection. During the mean follow-up period (12.4+/-1.9 months), no patient in the manubrium-sparing sternotomy group reported significant discomfort or pain due to the sternotomy, but 6 patients (23.1%) in the full sternotomy group complained of significant sternal pain, while 4 (15.4%) experienced shoulder pain, and 1 (3.8%) experienced numbness of the 4th and 5th fingers of both hands. We conclude that the manubrium-sparing sternotomy is a safe and useful approach for most cardiac operations. It is effective in reducing surgical trauma and postoperative wound discomfort.

Adolescent↗

PubMed1999

[Aortic valve operations through an upper partial sternotomy].

The median sternotomy has been accepted as the most common approach to the heart, because this approach is easily opened and closed, and easy access to the entire heart is possible. Following the pioneering work by Cosgrove and colleagues of using a parasternal incision for aortic and mitral valve operations, several reports suggested that modified minimal access procedures are likely to be associated with reduced postoperative discomfort and faster recovery. Since July 1997, we have used an upper partial sternotomy and a limited skin incision for isolated aortic valve replacement (AVR) at our hospital. To demonstrate the benefits of this approach, we compared 14 AVR operations using our minimal access incision (group M) with 19 patients undergoing isolated AVR using a conventional sternotomy (group F). In the minimal access group of patients, a small skin incision was made from the second intercostal space to the fourth rib. The pectralis major and intercostal muscle was freed from the sternum, and then a transverse half sternotomy was made in the fourth intercostal space using a striker without injury to the right internal mammary artery. A median partial sternotomy from the supersternal notch to the level of the fourth intercostal space. Cardiopulmonary bypass was connected through the same access site to avoid cannulation of both groins. Conversion to median sternotomy was not necessary in any patient including reexploration for postoperative bleeding. There was no operative mortality, stroke, aortic dissection and perivalvular leaks due to technical factors. In group F, wound infection occurred in 1 patient. One patient in group M required reoperation to control postoperative bleeding. Although mean duration of operation, cardiopulmonary bypass, and cross clamp time in group M was not prolonged, the initiation of cardiopulmonary bypass and aortic crossclamp was delayed by difficulties of cannulations. The distance between the transverse sternotomy (lower edge of divided sternum) and the midpoint of aortic valve annulus was correlated with mean duration of cardiopulmonary bypass and cross clamp time. Our experience demonstrates that isolated AVR through an upper partial sternotomy allows the same quality operations as the full sternotomy, although more clinical experience is required to clarify the benefits of this approach. Excellent exposure of the aortic valve through a partial sternotomy may be attained, if an adequate approach can be selected by the position of aortic valve.

Aortic Valve↗

PubMed2002

[Closure of atrial septal defect via small lateral thoracotomies, partial and full length sternotomies].

Surgical closure of atrial septal defect is considered a low risk procedure. Various minimally invasive surgical techniques spread over the conventional full-length sternotomy. But the risk profile and complication rates of the minimally invasive closure of atrial septal defect are not revealed sufficiently. We present the results of atrial septal defect surgery via small thoracotomies: right anterolateral, right posterolateral, partial sternotomies and full-length median sternotomies. Ninety four patients underwent surgical closure of atrial septal defect via minimal approaches through the period from February 1999 to December 2001. Via median sternotomies were operated 85 patients. Right anterolateral group consisted of 17 patients, right posterolateral - 68, partial sternotomies - 9. The intracardiac period of operation was performed on electrical fibrillation under mild hypothermia. Median bypass time was 33 min. in right anterolateral, 31 min. - right posterolateral, 32 min. - partial sternotomies, 37 min. - median sternotomies. Median fibrillation time was 21 min. in right anterolateral, 18 min. - right posterolateral, 15 min. - partial sternotomies, 21 min. - median sternotomies. There were no technical procedure related complications in minimally invasive group. Intrahospital morbidity consisted of 6 pneumonias, 4 pleural effusions. There were 3 pneumonias, 2 pleural and 2 pericardial effusions in median sternotomies group.

Adolescent↗

PubMed1993

Median sternotomy.

Although median sternotomy was succinctly described in 1897, "Milton's procedure" was essentially unused until it was recommended in 1957. With the advent of coronary bypass operation in 1968, median sternotomy became one of the most commonly performed surgical procedures. Even with the increasing use of median sternotomy for cardiac operations, thoracic surgeons have been reluctant to apply this operative modality in their practice. This is understandable because most pulmonary problems present in a distinctly unilateral manner and the tendency of most thoracic surgeons is to avoid median sternotomy in favor of the more familiar lateral thoracotomy. However, with the increasing use of CT scans of the chest, more patients with bilateral pulmonary pathologic factors are being identified. Median sternotomy is ideally applicable to this patient group for preservation of pulmonary function and for diminishing patient discomfort. Certainly, median sternotomy is infinitely preferable to staged bilateral thoracotomy if the same therapeutic goals can be accomplished. Younger thoracic surgeons who are trained in cardiac operation are less reluctant to use median sternotomy in the treatment of noncardiac disorders. This factor may account for the recent reports of increased usage of median sternotomy. It is a very natural tendency to use that with which one is familiar. Nonetheless, median sternotomy, other than for cardiac operation, is currently underused. The situation may ultimately be corrected as the use of median sternotomy is more fully appreciated. This relatively atraumatic, nonmuscle dividing approach to the anterior mediastinum, heart, lungs, diaphragm, pleural cavities, aortic arch and great vessels and liver deserves to be seriously considered as an appropriate alternative to more familiar, but more traumatic, approaches.

Humans↗

PubMed2004

Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair.

OBJECTIVE: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches. METHODS: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7+/-8.2 years; mean time interval for development of aneurysm was 3.6+/-4.2 years; mean age at aneurysm surgery was 16.9+/-8.8 years. Residual left to right shunt was detected in 6 (46%) patients. RESULTS: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6+/-5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up. CONCLUSION: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-right-lateral positioning of the patient.

Adolescent↗

PubMed1987

Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve.

Median sternotomy is the most common approach for repeat cardiac surgery despite the potential complications of cardiac injury. Right anterolateral thoracotomy has been recommended as an alternative for patients undergoing mitral valve replacement, but data supporting one approach over the other do not exist. To compare these procedures, the records of 43 patients who had had a previous median sternotomy and who underwent mitral valve replacement were reviewed. No statistically significant differences between patients undergoing repeat median sternotomy (33 patients) and those undergoing right anterolateral thoracotomy (10 patients) were demonstrable when compared for age, gender, New York Heart Association Functional Class, other diseased valves, urgency of operation, indication for operation, type of valve removed, type of valve implanted, length of postoperative hospitalization, length of operation, days of ventilatory support, length of intensive care unit stay, and survival (90% for thoracotomy group; 76% for median sternotomy group; p, NS). Significant differences between the two groups, favoring right anterolateral thoracotomy, were apparent when comparisons were made for length of perfusion (means, 94.8 min, thoracotomy group; 121.4 min, sternotomy group; p = .03), incidence of reexploration (0%, thoracotomy group; 13%, sternotomy group; p = .001), and blood transfusion (means, 5.3 units, thoracotomy group; 11.4 units, sternotomy group; p = .003). Right anterolateral thoracotomy is an effective alternative to repeat median sternotomy for replacement of the mitral valve in patients who have had a previous median sternotomy.

Heart Valve Prosthesis↗

PubMed2001

Chronic post-sternotomy pain.

BACKGROUND: Chronic postoperative pain is a well-recognised problem. The incidence of severe incapacitating pain is about 3-5% after various types of surgery such as thoracotomy, repair of inguinal hernias and mastectomy. Sternotomy causes considerable postoperative pain and patients with chronic post-sternotomy pain are often referred to pain clinics. Epidemiological studies on chronic post-sternotomy pain are scarce, however. The aim of this paper was to study the incidence and possible risk factors of chronic pain following sternotomy operations performed for coronary bypass grafting or thymectomy. METHODS: Two groups of patients were studied for persistent pain following sternotomy operations. A questionnaire was sent in January 1997 to 71 patients with myasthenia gravis (MG) who had undergone a thymectomy during 1985-1996 and 720 patients who had had coronary bypass grafting (CABG) in 1994 were interviewed by letter. The patients were asked about the presence of pain and other symptoms in the chest, shoulders, arms or legs that they thought were connected to surgery. They were also asked about the quality of the pain and its evolvement with time. The patients' records were checked for details about surgery, anaesthesia and the state of the coronary disease. RESULTS: The response rate was 87%. The interval between the interview and surgery varied from 6 months to 12 years in the MG group and it was 2-3 years in the CABG group. In the MG group, 27% of the patients reported chronic post-sternotomy pain, which was moderate to severe in 48% of the patients. In the CABG group, 28% of the patients still had post-sternotomy pain, which was moderate to severe in 38% of patients. Of the patients who had post-sternotomy pain, one-third reported sleep disturbances due to the pain. CONCLUSION: Chronic post-sternotomy pain is an important complication that may have a significant impact on the patient's everyday life. Future studies will show whether minimising complications, improving postoperative care and starting early adequate pain management will reduce the incidence of this problem.

Adolescent↗

PubMed2006

Partial median sternotomy: an attractive approach to mediastinal parathyroid disease.

BACKGROUND: Parathyroid exploration through a standard cervical approach is adequate for the resection of most mediastinal parathyroid glands. A subset of mediastinal parathyroid glands causing hyperparathyroidism, however, cannot be removed in this manner. STUDY DESIGN: We reviewed our experience with the use of partial median sternotomy in the treatment of these patients. RESULTS: Over a 14-year period, all but 10 of 937 (1.1%) consecutive patients explored for hyperparathyroidism by a single endocrine surgeon were treated by a cervical approach. Partial median sternotomy was performed in 10 cases and was successful in seven cases (70%), with conversion to a complete sternotomy being required in three cases. Six of these seven patients had failed a previous parathyroid exploration (86%), including one patient who had a previous complete sternotomy. Cure of hyperparathyroidism was achieved in all seven patients undergoing partial median sternotomy. In five patients a mediastinal parathyroid gland was removed (71%), and in one patient a parathyroid adenoma in the carotid sheath was eventually found, and the location of the hyperfunctioning parathyroid gland in one patient was never determined although the patient was cured. The mean length of hospital stay after a partial median sternotomy was 2.6 days. One patient sustained a recurrent laryngeal nerve injury at the time of a repeat cervical exploration and partial median sternotomy. CONCLUSIONS: Rarely, mediastinal parathyroid glands cannot be resected through a cervical approach. In these cases the use of partial median sternotomy is an attractive technique in achieving cure of hyperparathyroidism and is associated with minimal morbidity and a short length of hospital stay.

Humans↗

PubMed1994

Effect of lung inflation and sternotomy direction on pleural space violation.

Patients often are disconnected temporarily from the ventilator before sternotomy to avoid entering the pleural space with the sternal saw. Although this practice is widespread, it is based on questionable physiologic principles. To evaluate the efficacy of this maneuver in reducing the incidence of pleural space violation with first-time sternotomy, 126 cardiac patients were randomized prospectively to either lungs inflated or deflated during sternotomy with the surgeon blinded to the particular assignment. The incidence of pleural space violation overall was 12%, occurring in 15% of patients with deflated lungs and in 9% of those with inflated lungs (p = 0.455 by chi 2 test). Examining the effect of the direction of sternotomy on pleural space entry revealed a 4% incidence with sternotomy starting at the xiphoid versus a 21% incidence with sternotomy starting at the sternal notch (p = 0.009 by chi 2 test). Preexisting hyperinflation of the lungs as evaluated by chest radiograms did not influence the incidence of pleural space violation. To reduce pleural space violation, sternotomy should be performed from the xiphoid to the sternal notch. More importantly, disconnecting the patient from the ventilator does not reduce pleural space violation with sternotomy and its further use is not indicated. These findings are discussed in the context of relevant heart-lung pathophysiology.

Cardiac Surgical Procedures↗

PubMed2006

Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study.

BACKGROUND: The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined. METHODS: Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed. RESULTS: Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001). CONCLUSIONS: Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

Aged↗

PubMed1998

Mitral valve operation via Port Access versus median sternotomy.

OBJECTIVE: The advantages and disadvantages of minimally invasive Port Access mitral valve operation have not been defined relative to standard median sternotomy. A study was therefore designed to delineate differences in outcome from mitral operation via Port Access versus sternotomy in comparable patients. METHODS: The records of 41 consecutive patients undergoing isolated mitral valve replacement (n = 14) or repair (n = 27) were examined. All operations were performed using cardioplegic arrest through either median sternotomy (n = 20) or a small right anterolateral thoracotomy using an endoaortic clamp and catheter system (Heartport, Redwood City, CA) to arrest and decompress the heart (Port Access, n = 21). RESULTS: Both groups were well matched for age, mitral pathology, ejection fraction, and comorbidity. except that Port Access patients were less likely to be female. Three patients had undergone previous cardiac operations. Surgical procedure time was longer for Port Access patients (384+/-80 vs. 263+/-41 min, P < 0.05). Port Access provided significantly smaller incision length (8+/-2 vs. 26+/-2 cm, P < 0.01) and similar or shorter hospital stay (6+/-4 vs. 7+/-3 days). Port Access provided excellent visualization of the mitral valve and subvalvular apparatus, generally better than sternotomy, to allow complex mitral valve repairs. The greatest advantage of Port Access mitral operation was that Port Access patients returned to normal activity more rapidly (4+/-2 vs. 9+/-1 weeks, P = 0.01) than did patients undergoing standard median sternotomy. CONCLUSIONS: By avoiding a sternotomy, Port Access mitral valve operation provided a smaller incision and a dramatically more rapid return to normal activity than did median sternotomy. Port Access cardioplegic arrest with the Heartport system allowed visualization of the mitral valve superior to median sternotomy and has become the standard approach at this institution.

Case-Control Studies↗