Cardiac Surgery Team Research Articles

Commentator Discussion: A novel, multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

Commentator Discussion: A novel, multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

A novel multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

ObjectiveTo characterize cognitive workload (CWL) of cardiac surgery team members in a real-world setting during coronary artery bypass grafting (CABG) surgery using providers’ heart rate variability (HRV) data as a surrogate measure of CWL. MethodsHRV was collected from the surgeon, anesthesiologist, perfusionist, and scrub nurse, and audio/video recordings were made during isolated, nonemergency CABG surgeries (n = 27). Eight surgical phases were annotated by trained researchers, and HRV was calculated for each phase. ResultsSignificant differences in CWL were observed within a given role across surgical phases. Results are reported as predicted probability (95% confidence interval [CI]). CWL was significantly higher for anesthesiologists during “preparation and induction” (0.57; 95% CI, 0.42-0.71) and “anastomoses” (0.44; 95% CI, 0.30-0.58) compared to other phases, and the same held for nurses during the “opening” (0.51; 95% CI, 0.37-0.65) and “postoperative” (0.68; 95% CI, 0.42-0.86) phases. Additional significant differences were observed between roles within a given surgical phase. For example, surgeons had significantly higher CWL during “anastomoses” (0.81; 95% CI, 0.69-0.89) compared to all other phases, and the same was true of perfusionists during the “opening” (0.79; 95% CI, 0.66-0.88) and “prebypass preparation” (0.50; 95% CI, 0.36-0.64) phases. ConclusionsOur innovative analysis demonstrates that CWL fluctuates across surgical procedures by role and phase, which may reflect the distribution of primary tasks. This corroborates earlier findings from self-report measures. The data suggest that team-wide, peak CWL during a phase decreases from early phases of surgery through initiation of cardiopumonary bypass (CPB), rises during anastomosis, and decreases after termination of CPB. Knowledge of these trends could encourage the adoption of behaviors to enhance team dynamics and performance.

EGS P24 Management of oesophageal denture impaction and complications - a case series

Abstract Background Dentures are sometimes inadvertently ingested and can impact in the oesophagus. This can lead to complications such as mediastinitis, perforation and major vascular fistulae. In 1914, Chiari coined ‘aorto-oesophageal syndrome’ following foreign body ingestion. Usually diagnosed post-mortem, he described a triad of chest pain, haematemesis and cardiac arrest resulting from perforation and aortic fistula. Modern dentures are radiolucent, have complex configurations and commonly impact in the oesophagus at the level of the aortic arch. Early specialist intervention by experienced oesophago-gastric (OG) surgeons is crucial to the prognosis. We present our personal experience of managing oesophageal denture impaction and complications. Methods A retrospective review of electronic health records of the authors’ case series of patients with a diagnosis of oesophageal denture impaction over a 13-year period from 01/01/2010 to 31/12/2022 was performed. The inclusion criteria was adult patients with a clinical diagnosis of oesophageal denture/dental bridge impaction. Pathology and complications from impaction and mode of intervention was reviewed. Other outcome measures evaluated were treatment complications, length of stay and 90-day mortality. Results Seven patients (6 males) with median age 54 were reviewed. Dentures were impacted at or above the aortic arch in 6 patients. Attempted retrieval with ENT rigid scope in 3 caused migration of denture causing perforation. Attempted retrieval with flexible gastroscope was successful in 3 but led to opening up of a fistula in one. Five patients underwent surgical intervention (results summarised in tables 1 and 2). 90-day mortality was 0%. The median length of stay in the surgical intervention group was 30 days. Two patients who had aorto-oesophageal fistulae required additional input by cardiac surgery and vascular radiology teams. Conclusions This is a report of the authors’ experience of managing oesophageal denture impaction and it’s sequelae. A favourable 0% 90-day mortality rate despite complex presentations including aorto-oesophageal fistulae has been described. For patients presenting with haematemesis or prolonged history of denture impaction a triple phase CT scan should be performed prior to intervention. The variable complex configuration of dentures complicates their impaction or attempts at extraction. Attempts at extraction with a rigid endoscope can lead to oesophageal perforation. Successful management of these complex cases requires an effective multidisciplinary approach in a specialist OG surgery centre.

Evaluation of Major Adverse Cardiac Events After Cardiac Surgery in Gaza

Background: The present study assessed the major adverse cardiac events (MACE) (hospital mortality rate, major stroke and reintervention) after cardiac surgery du to coronary artery bypass grafting or valve surgery or both in the Ministry of health hospitals (MOH) in Gaza Strip at 2022 by either Local or Expert cardiac surgery team.

Meet Jolanda Kluin, new associate editor for the cardiac and vascular surgery team.

Meet Jolanda Kluin, new associate editor for the cardiac and vascular surgery team.

Developing and Maintaining the Robotic Cardiac Surgery Team

The development of a successful robotic cardiac surgery program is closely related to the development of the cardiac surgery robotic team. Growth of the program in volume and complexity of the procedures is facilitated by a highly functioning team. The surgeon leader remains the cornerstone of this team; however, success depends on the growth and development of the team.

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

Crisis Scenarios for Simulation-Based Nontechnical Skills Training for Cardiac Surgery Teams: A National Survey Among Cardiac Anesthesiologists, Cardiac Surgeons, Clinical Perfusionists, and Cardiac Operating Room Nurses.

Nontechnical skills in cardiac surgery are vital in ensuring patient safety in the operating room (OR). To train these skills in a simulation-based scenario, a collection of commonly accepted crisis scenarios is needed to serve as a framework for a simulation-based training program. The objective of this study was to identify and reach consensus on a collection of relevant crisis scenarios in cardiac surgery suitable for simulation-based team training focusing on nontechnical skills. Using the Delphi method, a national assessment was performed among cardiac surgeons, cardiac anesthesiologists, clinical perfusionists, and cardiac OR nurses in the Netherlands. In the first Delphi round, potential crisis scenarios for simulation-based team training in cardiac surgery were identified. In the second round, the identified scenarios were rated using a 5-point Likert scale. Finally, based on consensus (two-thirds majority), scenarios were prioritized and explored for feasibility. One hundred fourteen experts participated in the study (26 cardiac anesthesiologists, 24 cardiac surgeons, 25 clinical perfusionists, and 39 OR nurses), representing all 16 cardiac surgical centers in the Netherlands. In the first round, 237 scenarios were identified. After eliminating duplicates and grouping similar scenarios, 44 scenarios were scored in round 2, which finally resulted in 13 relevant crisis scenarios with an expert consensus higher than 67%. Thirteen crisis scenarios relevant to simulation-based team training were identified by an expert panel consisting of all members of the cardiac surgical team. Further research is needed to evaluate the educational value of the respective scenarios.

Impact of Bedside Balloon Atrial Septostomy in Neonates with Transposition of the Great Arteries in a Neonatal Intensive Care Unit in Romania.

(1) Background: Transposition of the great arteries (TGA) is the most common congenital heart disease, accounting for 5-7% of all cardiac anomalies, with a prevalence of 0.2-0.3 per 1000 live births. (2) Aim: Our main objectives were to evaluate the clinical safety of balloon atrial septostomy in neonates and the possible complications. Furthermore, we tried to establish whether the procedure should be performed in all TGA patients with small atrial septal defects, regardless of oxygen saturation, within a center where corrective surgery cannot be performed on an emergency basis due to the lack of a permanent cardiac surgery team for arterial switch surgery. (2) Methods: We conducted an observational, retrospective, single tertiary-care center study between January 2008 and April 2022, which included 92 neonates with TGA transferred to our institution for specialized treatment. (3) Results: The median age at the time of the Rashkind procedure was four days. The rate of immediate complications after balloon atrial septostomy (BAS) was high (34.3%), but most were transient (metabolic acidosis and arterial hypotension-21.8%). Twenty patients with TGA managed in our hospital underwent definitive and corrective surgical intervention (arterial switch operation) at a median age of 13 days. Most patients (82.6%) were term neonates, but 16 were born preterm. (4) Conclusions: Urgent balloon atrial septostomy is often the only solution to restore adequate systemic perfusion. Bedside balloon atrial septostomy is a safe, effective, and initial palliative intervention in neonates with TGA, which can be performed in the neonatal unit.

Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study

ObjectivesTo estimate the impact of the organisational model of transvenous lead extraction (TLE) on effectiveness and safety of procedures.DesignPost hoc analysis of patient data entered prospectively into a computer database.SettingData...

Association between preoperative on-site CCU visits and postoperative delirium in patients undergoing cardiac surgery: A retrospective cohort study.

Postoperative delirium (POD) is a common complication after cardiac surgery (CS), with symptoms like attention disorders and even delays patients' recovery. To evaluate the impact of preoperative on-site visits in the cardiac care unit (CCU) on POD after CS. Patients admitted to the CCU with extracorporeal CS were included in the visiting or non-visiting group according to whether they were on visiting week. The visiting group received a preoperative visit from a nurse-led multidisciplinary visiting team (including CCU nurses and physicians) 1 week before surgery in addition to standard care. The non-visiting group received standard care like unstructured information from the CS team and anesthesiologists and so on. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were used to evaluate the POD severity. The incidence, occurrence and duration of POD, as well as the CCU length of stay, postoperative mechanical ventilation duration and length of hospital stay were compared between the two groups. A total of 735 participants (369 in the visited group and 366 in the unvisited group) were included in this study. Preoperative on-site visits were associated with a decreased POD incidence (odds ratio [OR]: 0.524, 95% CI: 0.336-0.817), an improved POD severity (OR: 0.578, 95% CI: 0.359-0.932) and a shortening POD duration (OR: 0.972, 95% CI: 0.951-0.994). There was a significant difference between the visiting and non-visiting groups in the mechanical ventilation duration (OR: 0.987, 95% CI: 0.978-0.996). Preoperative on-site visits are associated with a reduction in the incidence, duration, and severity of POD, as well as the mechanical ventilation duration of patients. This study found that preoperative on-site visits were associated with the onset, duration, severity and duration of mechanical ventilation of POD. Although many factors influence the occurrence of POD, a multidisciplinary visiting team led by a nurse (including CCU nurses and physicians) can provide early nursing interventions through preoperative visits, better obtain postoperative cooperation from patients, establish a good nurse-patient relationship and provide better health services to patients. In a realistic CCU setting, nurses and physicians can act as educators, assessing patients before surgery, enhancing preoperative education, improving patient familiarity with the CCU environment and teaching sign language communication skills when patients are mechanically ventilated. These findings can therefore provide the basis for effective clinical care to prevent postoperative POD.

Impact of shift work on surgical outcomes at different times in patients with acute type A aortic dissection: A retrospective cohort study.

To investigate the effect of shift work on surgical outcomes at different times in patients with acute type A aortic dissection (ATAAD). Patients with ATAAD who underwent total arch replacement at Qilu Hospital of Shandong University from January 2015 to March 2022 were retrospectively analyzed. All patients were managed according to the green channel emergency management strategy, and a professional cardiac team was arranged during off-hours. Based on surgery time and symptom onset to procedure time, the patients were divided into weekday, weekend and holiday groups; daytime and nighttime groups; intervention time ≤48 h and >48 h groups; working hours and off-hours groups. In-hospital mortality between these groups was compared. In total, 499 ATAAD patients underwent surgery within 7 days of symptom onset, and the in-hospital mortality rate was 10% (n = 50/499). Among the 499 patients, 320 (64.13%), 128 (25.65%) and 51 (10.22%) underwent surgery on weekdays, weekends and holidays, respectively. In-hospital mortality and 7-day mortality showed no significant difference among the three groups. Two hundred twenty-seven (45.5%) underwent daytime surgery, and 272 (54.5%) underwent nighttime surgery. Durations of ICU stay and hospital stay were significantly different between the two groups (P < 0.05). There was no significant differences in in-hospital mortality (9.2% vs. 10.7%) and 7-day mortality (4.4% vs. 6.6%). 221 patients (44.3%) and 278 patients (55.7%) were included in the intervention time ≤48 h and >48 h groups, respectively. Acute renal injury, ICU stay and hospital stay were significantly different (P < 0.05) whereas 7-day mortality (5.0% vs. 6.1%) and in-hospital mortality (8.6% vs. 11.1%) were not. Furthermore, 7-day (1.9% vs. 6.6%) and in-hospital mortality (11.1% vs. 9.8%) showed no difference between working hours group (n = 108) and off-hours group (n = 391). Cox regression analysis showed that postoperative acute renal injury (HR = 2.423; 95% CI, 1.214-4.834; P = 0.012), pneumonia (HR = 2.542; 95% CI, 1.186-5450; P = 0.016) and multiple organ dysfunction (HR = 11.200; 95% CI, 5.549-22.605; P = 0.001) were the main factors affecting hospital death in ATAAD patients. Under the management of a professional cardiac surgery team with dedicated off-hours shifts, surgery time was not related to in-hospital mortality in ATAAD patients.

Complications and their management in robotic mitral valve surgery from the surgical assistant's perspective.

Robotic mitral valve (MV) repair is an alternative approach to traditional MV repair via median sternotomy. There is a rich history of innovation embedded within robotic MV surgery. Since the inaugural robotic MV repair performed in May 1998 by Carpentier, progressive techniques and expanding indications have given surgeons the opportunity to offer an increasing number of their patients access to robotic MV surgery. This, coupled with less cynicism surrounding robotic and minimally invasive surgery, has stimulated robotic cardiac surgery program development and the number of robotic MV procedures performed annually. Utilizing the robotic technology in MV surgery is far from the standard of care and must be approached modestly by only well trained and experienced cardiothoracic surgeons and teams. Advanced surgical techniques provide numerous opportunities for complications and adverse outcomes. It is essential for the entire robotic cardiac surgery team to be aware of the additional risks during each step of the procedure. The fundamental principle of robotic MV repair is to avoid complications with anticipation. No surgery is without risk, and unfortunately, some of those risks are unavoidable. If a complication does occur, it is essential the surgeon and robotic team understand their roles and how to triage the event. This keynote lecture will outline each phase of the robotic MV repair surgery before, during and after the patient cart is docked to the patient. Within each phase we will identify potential complications and their management.

ELECTRICAL STORM FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN A PATIENT WITH HYPERTHYROIDISM: A CASE REPORT

An electrical storm, dened as repeated ventricular arrhythmia has been reported as a relatively rare but challenging event. We report a case of an electrical storm following coronary artery bypass grafting (CABG) surgery in a 49-year-old man with untreated hyperthyroidism. The patient underwent successful CABG surgery after being diagnosed with ST elevation myocardial infarction and three vessel disease of coronary artery. Six days after the operation, ventricular tachy-arrhythmias were continuously observed, and direct current cardioversions were performed more than 30 times over 24 hours. Based on laboratory test results, the patient had persistent hyperthyroidism, and we continued anti- thyroid therapy and anti-arrhythmic medication. Eventually, the patient was successfully treated with a second trial of catheter ablation. In conclusion, physicians must carefully manage thyroid function in patients undergoing cardiac surgery. We also recommend that cardiac surgery teams take a multidisciplinary perioperative approach to critical care for cardiac surgery.

The impact of initiating quality of care improvement protocols on intensive care unit length of stay in patients undergoing coronary artery bypass grafting: An insight from a nascent program

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Prolonged intensive care unit (ICU) length of stay (LOS) post coronary artery bypass grafting (CABG) constitutes a major challenge for both patients and cardiac surgery teams. While Identifying predictors of prolonged patients’ stay in the ICU can further optimise ICU resource utilization, the role of initiating QOC improvement protocols aimed to reduce ICU LOS for these patients has been widely advocated. Therefore, we aim in our study to evaluate the overtime impact of initiating QOC improvement protocols on ICU LOS and present patient characteristics predicting prolonged ICU stay in patients undergoing CABG in a nascent program. Methods We included consecutive patients (n=976) undergoing CABG at a newly established tertiary centre between June 2015 and September 2021. Data on baseline characteristics and presentation, in addition to intraoperative details and outcomes, were collected retrospectively. Patients with prolonged (≥48h) and short (&amp;lt;48h) ICU LOS were compared by appropriate testing methods. Predictors of prolonged ICU LOS were determined by multivariable logistic regression. Continuous development of ongoing protocols to improve QOC was taken, including but not limited to; enhancing diabetic control, coronary perfusion and renal function. Trends in prolonged ICU LOS were determined using Joinpoint Software of the National Cancer Institute to calculate the average annual percentage change (AAPC). Results QOC improvement protocols initiation was associated with a 33.7% reduction in the proportion of patients having prolonged ICU LOS post- CABG between 2015 to 2021 ( AAPC: -5.3 , 95%CI [-7.7, -2.9], p&amp;lt;0.001) . Overall, 56.4% (551/976) of patients had prolonged ICU LOS. In comparison to individuals with short ICU LOS, patients who overstayed in the ICU were significantly older, females, diabetic, with higher burden of peripheral vascular disease (Table). On presentation, the prolonged LOS group was featured by worse NYHA class, higher rates of acute myocardial infarction (MI), lower ejection fraction (EF), higher serum creatinine and more frequently required preoperative intra-aortic balloon pump (IABP) insertion (Table). Aortic cross-clamp time and type of surgery were comparable between groups. Unfavorable outcomes were noticed in the prolonged ICU LOS group regarding postoperative adverse events and mortality. On multivariable logistic regression, age, female gender, NYHA class ≥II, MI on presentation, preoperative creatinine level, preoperative EF and preoperative IABP placement were independent predictors for prolonged ICU LOS (Figure). Conclusion In this study, initiation of QOC improvement protocols was associated with a significant reduction in prolonged ICU LOS. While multiple risk factors prolonging ICU LOS were identified, future studies are required to further incorporate these risk factors into ongoing protocols aimed to optimise resources utilisation and enhance the QOC in CABG patients.

The teamwork structure, process, and context of a paediatric cardiac surgery team in Mongolia: A mixed‐methods approach

IntroductionEffective teamwork in paediatric cardiac surgery is known to improve team performance and surgical outcomes. However, teamwork in low‐ and middle‐income countries (LMICs), including Mongolia, is understudied. We examined multiple dimensions of teamwork to inform a team‐based training programme to strengthen paediatric cardiac surgical care in Mongolia.MethodsWe used a mixed‐methods approach, combining social network analysis and in‐depth interviews with medical staff, to explore the structure, process, quality, and context of teamwork at a single medical centre. We conceptualised the team's structure based on communication frequency among the members (n = 24) and explored the process, quality, and context of teamwork via in‐depth interviews with select medical staff (n = 9).ResultsThe team structure was highly dense and decentralised, but the intensive care unit nurses showed high betweenness‐centrality. In the quality and process domain of teamwork, we did not find a regular joint decision‐making process, leading to the absence of common goals among the team members. Although role assignment among the medical staff was explicit, those strictly defined roles hindered active communication about patient information and responsibility‐sharing. Most interviewees did not agree with the organisational policies that limited discussions among team members; therefore, medical staff continued to share training and work experiences with each other, leading to strong and trustworthy relationships.ConclusionThe findings of this study underscore the importance of well‐structured and goal‐oriented communication between medical staff, as well as the management of the quality of collaboration within a team to increase teamwork effectiveness in paediatric cardiac surgery teams in LMICs.

The National Blood Shortage-An Impetus for Change.

The National Blood Shortage-An Impetus for Change.

Robotic Off-Pump Totally Endoscopic Coronary Artery Bypass in Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

Značaj funkcije desne srčane komore za ishod lečenja i remodelovanje srca nakon implantacije uređaja za trajnu mehaničku cirkulatornu potporu leve komore

The efficiency of the device for permanent circulatory support of the left ventricle has been proven through clinical practice with the trend of constant improvement of treatment results along with biotechnological progress and improvement of surgical implantation techniques. The published reports of most reference cardiac surgery centers present a one-year survival rate of over 85%, a two-year survival rate of 70% and a five-year survival rate of 45-50%. In addition to clear benefits for the patient, implantation of LVAD also carries significant specific risks, so infections, post-implantation bleeding, strokes, and right ventricular postimplantation weakness are the most common complications. Given that the progress of the LVAD program is ensured primarily by reducing the incidence of complications not related to the functioning of individual segments of the cardiovascular system, and as left ventricular function is completely replaced by LVAD device, the most recent challenge is the decision to install LVAD device in the heart with right ventricular, given that the postimplantation weakness of right ventricular is associated with proven increased mortality and morbidity. Since the 1990s, studies on hearts with implanted LVAD as a bridge to heart transplantation have shown regression of cell hypertrophy, normalization of cell size, muscle fiber architecture, and heart chamber geometry. The described changes are characterized by the notion of reverse remodeling, which is synonymous with function recovery. It is this process at the level of the right ventricle that is recognized as extremely important for the success of LVAD programs, especially in the group of patients who have a certain degree of right ventricular weakness preoperatively. The basic requirements of the cardiac surgery team are adequate preoperative assessment of right ventricular weakness, then application of measures to prevent damage and load on the right ventricle during and after LVAD implantation, as well as providing adequate therapeutic measures for right ventricular recovery in the postimplantation period.

STERNOTOMY CLOSURE AFTER HISTORY OF MAJOR STERNAL RESECTION FOR MALIGNANT DISEASE

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sternal closure after resections for the benign or malignant disease has always been a topic of discussion based on the need for adequate closure and coverage of the chest. The dreaded complication of deep space infection or sternal dehiscence after a sternal resection is a real concern among the cardiothoracic surgery community as these complications can lead to significant morbidity and mortality. We present a case of a 69-year-old female with a history of a large left inferior sternal resection due to malignant disease undergoing closure of her sternum after an on-pump coronary artery bypass. CASE PRESENTATION: A 69-year-old female with a past medical history of hypertension, depression, and smoking presented to the hospital with a chief complaint of chest pain. The patient was found to have shortness of breath with pain radiating to both of her arms. She was found to have a STEMI with an acute inferior wall infarction on EKG and an elevated troponin of 748. The patient was taken emergently to the cath lab and was found to have multivessel coronary artery disease with a preserved left ventricular function. The patient was continued on heparin and evaluated by the cardiac surgery team. She was taken for coronary artery bypass with bypass of the obtuse marginal and left anterior descending arteries. Upon opening the chest, we noted she had a large piece of her left inferior sternum missing from her previous surgery. The manubrium remained intact, the decision was made at the time of her chest closure to use a sternal locking system on the manubrium and upper portion of her sternum for added strength and support of her previous sternal resection. The patient's postoperative course was uneventful, and she was discharged home. On clinic follow up she had excellent healing of her sternal wound with no signs of dehiscence. DISCUSSION: Closure of a sternotomy site after resection of a large portion of the sternum is a major risk factor for potential noninfectious dehiscence that could lead to infection especially if the bone quality is poor or if there is minimal sternum left to close the chest. There is limited data about the closure of a sternotomy after a major portion of the sternum has been previously resected due to malignant disease in the past. When minimal manubrium or sternum remains after resection, we recommend plating for added strength of the sternal closure. CONCLUSIONS: Sternal dehiscence with complications is a major concern after sternotomy is performed. The risk for sternal dehiscence is even greater when the patient has had a previous sternal resection with minimal sternum remaining. We highly recommend using a sternal plate locking closure device when closing a previous sternum that has had a major sternal resection. The plating system provides stronger closure and will help to avoid the dreaded complication of dehiscence even when there is minimal sternum remaining. REFERENCE #1: Adel M., F. Alhalawani, et al. A review of sternal closure techniques: J Biomater Appl.2013 Nov 483-497 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response