Median Sternotomy Group Research Articles

Choice of incision in penetrating cardiac injuries: Which one must we prefer: Thoracotomy or sternotomy?

Penetrating cardiac injuries are high-risk, high-mortality injuries considering the outcomes. Therefore, it is important to choose the appropriate incision. In general clinical settings, thoracotomy and median sternotomy are choices of incisions to explore the injury. In this study, the results of median sternotomy and thoracotomy in penetrating cardiac injuries were compared. Between January 2003 and December 2013, forty patients, who underwent either thoracotomy or median sternotomy for penetrating cardiac injury, were retrospectively analyzed, and the collected data were compared. Twenty-six patients underwent thoracotomy (Group 1), and fourteen patients underwent median sternotomy (Group 2). There was no statistically significant gender difference between the groups. However, the mean age in Group 2 was found to be significantly higher than the one in Group 1 (p<0.05). There were no significant survival differences between the groups in the long term. Incision choice should be determined considering the site of injury and whether there is an accompanying pulmonary injury or not. On the other hand, thoracotomy has some draw backs compared to median sternotomy.

Plasma and Tissue Pharmacokinetics of Cefazolin in an Immature Porcine Model of Pediatric Cardiac Surgery

Background: Surgical Site Infection (SSI) prevention for children with congenital heart disease is imperative and methods to assess and evaluate the tissue concentrations of prophylactic antibiotics are important to help maximize these efforts. The purpose of this study was to determine the plasma and tissue concentrations of standard-of-care peri-operative cefazolin dosing in an immature porcine model of cardiac surgery and cardiopulmonary bypass. Methods: Piglets (3-5 days old) underwent either median sternotomy (MS) or cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB+DHCA) and received standard of care prophylactic cefazolin for the procedures. Serial plasma and microdialysis sampling of skeletal muscle and subcutaneous tissue adjacent to the surgical site was performed. Cefazolin concentrations were measured, non-compartmental pharmacokinetic analyses were performed, and tissue penetration of cefazolin was assessed. Results: Following the first intravenous dose, maximal cefazolin concentrations for plasma and tissue samples were similar between groups with peak tissue concentrations 15-30 minutes after administration. After the second cefazolin dose given with initiation of CPB, total plasma cefazolin concentrations remained relatively constant until the end of DHCA and then decreased while muscle and subcutaneous unbound cefazolin concentrations showed a second peak during or after rewarming. For the MS group, 60-67% of the intraoperative time showed tissue cefazolin concentrations greater than16 μg/mL while this percentage was 78-79% for the CPB+DHCA group. There was less tissue penetration of cefazolin in the group that underwent CBP+DHCA (P=0.03). Conclusions: The cefazolin dosing used in this study achieves plasma and tissue concentrations that should be effective against methicillin-sensitive Staphylococcus aureus but may not be effective against some gram-negative pathogens. The timing of cefazolin administration prior to incision and a second dose given during cardiopulmonary bypass may be important factors for achieving goal tissue concentrations.

Minimally invasive valve sparing aortic root replacement (David procedure) is safe.

Even though minimally invasive cardiac surgery may reduce morbidity, this approach is not routinely performed for aortic root replacements. The purpose of this pilot study was to assess the safety and feasibility of valve sparing aortic root replacement via an upper mini-sternotomy up to the 3(rd) intercostal space. Between April 2011 and March 2014, 26 patients (22 males, age 47.6±13 years) underwent elective minimally invasive aortic valve sparing root replacement (David procedure, group A). Twelve patients underwent additional leaflet repair. Concomitant procedures were: four proximal aortic arch replacements and one coronary artery bypass grafting (CABG) to the proximal right coronary artery (RCA). During the same time period, 14 patients (ten males, age 64.2±9.5 years) underwent elective David procedure via median full sternotomy (group B). Concomitant procedures included six proximal aortic arch replacements. Although the patient cohorts were small, the results of these two groups were compared. In group A, there were no intra-operative conversions to full sternotomy. The aortic cross-clamp and cardiopulmonary bypass (CPB) times were 115.6±30.3 and 175.8±41.9 min, respectively. One patient was re-opened (via same access) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.5±0.3 and 10.4±6.8 days, respectively. There was no 30-day mortality. The patient questionnaire showed that the convalescence time was approximately two weeks. In group B: the cross-clamp and CPB times were 114.1±19.9 and 163.0±24.5 min, respectively. One patient was re-opened (7.1%) due to post-operative bleeding. The post-operative ventilation time and hospital stay were 0.6±0.7 and 14.2±16.7 days, respectively. There was no 30-day mortality. Minimally invasive valve sparing aortic root replacement can be safely performed in selected patients. The results are comparable to those operated via a full sternotomy. The key to success is a 'step by step' technique of moving from minimally invasive aortic valve replacements (AVR) to more demanding aortic root replacements. Meticulous hemostasis & attention to surgical details is of utmost importance to prevent perioperative complications.

Long-term outcomes after thoracoscopic resection of stage I and II thymoma: a propensity-matched study.

The use of video-assisted thoracoscopic surgery (VATS) in patients with thymoma remains controversial. We sought to evaluate the perioperative and oncological outcomes after VATS resection for stage I and II thymoma and to compare the outcomes with those obtained after median sternotomy (MST). Between 1991 and 2007, a total of 140 patients with stage I and II thymoma underwent surgery at the Chang Gung Memorial Hospital. Of them, 58 underwent MST, 61 VATS, and 21 thoracotomy. Using a propensity score based on four variables (myasthenia gravis, tumor size on CT images, age, and Masaoka stage), 48 VATS-treated patients were matched to 48 patients who received MST. Outcomes compared included perioperative complications, length of stay, tumor recurrence, and survival. No operative deaths occurred in this study. VATS was associated with fewer intraoperative blood loss, and more patients in the VATS group were extubated in the operating room after surgery compared with the MST group (37.5 vs. 12.5 %, respectively, P = 0.005). The mean length of stay was shorter in the VATS group than in the MST group (5.8 vs. 7 days, respectively; P = 0.008). After a median follow-up of 53 months, five patients developed recurrent tumors (four pleural and one pericardial). No statistically significant differences were found in the 5-year survival rates between the two study groups. VATS appears feasible for patients with stage I and II thymoma and is associated with better perioperative outcomes than MST. The oncological outcomes are also similar.

Comparison of clinical outcomes and postoperative recovery between two open heart surgeries: minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy

ObjectiveTo compare the clinical outcomes of minimally invasive right subaxillary vertical thoracotomy and traditional median sternotomy through right atrium in treatment of common congenital heart diseases. MethodsClinical data of 59 cases of common congenital heart diseases treated with minimally invasive right axillary vertical thoracotomy from May, 2011 to February, 2013 and 77 cases of same diseases with traditional median sternotomy in the past three years were retrospectively analyzed, including atrial septal defect, membranous ventricular septal defect and partial endocardial cushion defect. The results were compared from the two groups, including the time for operation and cardiopulmonary bypass, amount of blood transfusion, postoperative drainage, ventilation time, hospital stay, and prognosis. ResultsNo severe complications happened in both groups, like deaths or secondary surgery caused by bleeding. No significant differences were in CPB time and postoperative ventilator time between groups (P>0.05), while for all of the operative time, the length of incision, postoperative drainage and hospital stay, minimally invasive right axillary vertical thoracotomy was superior to median sternotomy, with statistically significant differences (P<0.05). In six-month followup after operation, no complications of residual deformity and pericardial effusion were found in both groups by doing echocardiography, but mild pectus carinatum was found in 8 patients in the traditional median sternotomy group (traditional group), whereas patients in another group were well recovered. ConclusionsMinimally invasive right subaxillary vertical thoracotomy for common congenital heart diseases is as safe as traditional median sternotomy, without the increasing incidence of postoperative complications. Additionally, compared with traditional median sternotomy, minimally invasive right subaxillary vertical thoracotomy is better in the aspects of hidden incision, appearance, and postoperative recovery.

Three-Year Results of Repaired Barlow Mitral Valves via Right Minithoracotomy versus Median Sternotomy in a Randomized Trial

Objectives: To clarify whether the results of repair of a complex mitral lesion (Barlow valve) at the intermediate-term follow-up are independent of the mode of surgical access [minithoracotomy vs. median sternotomy (MS)]. Methods: In a prospective randomized study of mitral repair for Barlow disease using either a minimally invasive (MI) approach or MS, we achieved an average follow-up of 3 years (echocardiography, physical examination and quality of life). Mitral repair was achieved with polytetrafluoroethylene chordal implantation for both leaflets. Results: Both groups included 80 patients. Mechanical ventilation time and intensive care unit and hospital stay were shorter in the MI group (p = 0.01, p = 0.013 and p = 0.02, respectively). During the follow-up, 5 patients in each group (6.25%) displayed mild mitral regurgitation, while 2 patients in each group (2.5%) developed recurrent regurgitation graded as at least moderate/severe. The rate of mitral reoperation was 2.5% in the MI group and 1.25% in the MS group (p = 0.9). The overall follow-up mortality was 3.75% in both the MI and the MS groups. Conclusions: The 3-year results of repair of Barlow valves were satisfactory irrespective of the approach used to repair the valve. The advantages of MI surgery can be achieved in patients with mitral Barlow disease without concerns over the durability of repair.

Minimally-Invasive Implantation of Left Ventricular Assist Devices Improves the Operative Outcome in Adult Patients with Severe Heart Failure

Purpose Left ventricular assist devices (LVAD) are gaining more importance in the treatment of heart failure. The constant development of novel technologies in this field is being reflected by enhanced and considerably miniaturized LVAD-systems. However from a surgical point of view, complications like bleeding or right ventricular failure with liver impairment are still major hurdles in LVAD-therapy. Therefore, we recently developed a novel minimally invasive LVAD implantation technique in order to minimize complication rates and improve operative outcome. Methods and Materials We reviewed the early outcome of 100 consecutive end-stage heart failure patients (74% male, age 51,6 ± 12,6, DCM 49%, ICM 36%) who recently underwent LVAD (HVAD, HeartWare, USA) implantation in our institution between 2011 and 2012. Patients who were operated conventionally by a median sternotomy (group A; n = 65) were compared to patients receiving a minimal invasive upper hemisternotomy combined with an anterolateral thoracotomy (group B; n = 35). Results Intra-hospital-mortality was lower in group B (12,3% vs. 8,6%). ICU stay was significantly lower (p < 0,05) in group B (20,2 ± 4,9 days vs. 9,8 ± 2,7 days). Bleeding incidence was also significantly (p < 0,05) lower in group B (18.5% vs. 5,7%). Postoperative glutamate dehydrogenase (GLDH) levels were also significantly (p < 0,05) lower in group B (76,2 ± 238,5 U/L vs. 15,5 ± 52,1 U/L). None of the patients had a pump thrombosis. Conclusions Our data show that the applied minimally invasive LVAD-implantation technique improves the early postoperative outcome by improving survival and reducing bleeding events, liver impairment and postoperative ICU stay of terminal heart failure patients.

Two approaches for repeat cardiac surgery

BackgroundWith recent advances in post-operative care and surgical methods, the number of cardiovascular re-operations is increasing. We analyzed our institutional experience to evaluate the safety and efficacy of the approach methods for cardiac re-operations.MethodsBetween September 2007 and December 2010, we performed 208 cardiac re-operations, defined as surgery which was not performed within a month from the previous operation or during the same hospitalization for the same disease and reviewed retrospectively. According to the surgical approach, we divided patients into two groups: median sternotomy group (S-group, n = 146), and thoracotomy group (T-group, n = 62).ResultsThere were no differences in sex or mean interval from the first surgery to re-operation between the two groups. Mean cardiopulmonary bypass, adhesion dissection time, bleeding control time, and operation time were significantly shorter in the T-group. The need for transfusion (p = 0.001) during adhesion dissection and the chest tube drainage (p < 0.001) were significantly lower in the T-group. There were 10 operative deaths in the S-group (6.8%) and 5 in the T-group (8.1%) (p = 0.757). Pneumonia was the most common cause of death in both groups. Post-operative bleeding did not result in death and there were no cases of wound infection in the T-group.ConclusionsTwo approaches for repeated cardiac surgery were safe and effective in terms of mortality, wound infection, bleeding, operation time, adhesion dissecting time, and bleeding control time. We were able to obtain a good visual field and perform safe surgery by applying the thoracotomy method in selective patients for cardiovascular re-operation.

Incidence of postoperative atrial fibrillation in patients undergoing minimally invasive versus median sternotomy valve surgery

Atrial fibrillation (AF) after cardiac surgery is associated with increased morbidity and hospital length of stay. Our objective was to determine whether a minimally invasive approach to isolated valve surgery reduced the incidence of postoperative AF. Patients without a history of arrhythmia, who underwent isolated aortic or mitral valve surgery between January 2005 and August 2011, were included. The incidence of postoperative AF in those who underwent a minimally invasive approach was compared with that of patients undergoing median sternotomy surgery. Resource utilization was approximated on the basis of intensive care unit and total hospital lengths of stay. A total of 571 patients were identified (413 minimally invasive and 158 median sternotomy). No significant differences in baseline characteristics existed between groups. The incidence of postoperative AF (25% vs 37%; P=.002), use of intraoperative blood products (52% vs 83%; P<.001), and prolonged intubation (≥24 hours) (12% vs 20%; P=.008) were significantly less in the minimally invasive group. The intensive care unit and hospital lengths of stay were 45 hours (interquartile range [IQR], 28-66 hours) versus 53 hours (IQR, 45-91 hours) (P<.001), and 5 days (IQR, 4-7 days) versus 8 days (IQR, 6-11 days) (P<.001) for the minimally invasive and median sternotomy groups, respectively. Multivariable analysis revealed a decreased risk of postoperative AF in patients undergoing minimally invasive surgery (odds ratio, 0.4; 95% confidence intervals, 0.24-0.66; P<.001). A minimally invasive approach for isolated valve surgery reduces postoperative AF and resource use when compared with median sternotomy.

Outcomes of minimally invasive valve surgery in patients with chronic obstructive pulmonary disease

We hypothesize that minimally invasive valve surgery in patients with chronic obstructive pulmonary disease (COPD) is superior to the conventional median sternotomy approach. We retrospectively reviewed 2846 consecutive surgery performed at our institution between January 2005 and September 2010, and identified 165 patients with COPD who underwent isolated valve surgery. In-hospital mortality, composite complication rates, intensive care unit and total hospital length of stay of those who had undergone a minimally invasive approach were compared with a cohort that underwent a standard median sternotomy approach. Of the 165 patients, 100 underwent a minimally invasive approach and 65 had a median sternotomy. Baseline characteristics did not differ between the two groups. The mean age was 71 ± 11 years for the minimally invasive group and 68 ± 12 years for the median sternotomy group, (P = 0.31). In-hospital mortality was 1 (1%) in the minimally invasive group and 3 (5%) in the median sternotomy group, P = 0.14. Composite postoperative complications were significantly reduced in the minimally invasive group (30 versus 54%, P = 0.002). The median intensive care unit length of stay was 47 h (IQR 40-70) versus 73 h (IQR 51-112), P < 0.001, and the median postoperative length of stay was 6 days (IQR 5-9) versus 9 days (IQR 7-13), P < 0.001, for the minimally invasive and the median sternotomy groups, respectively. Minimally invasive valve surgery in patients with COPD is associated with excellent short-term results, and thus should be considered an option in these patients.

Minimally invasive aortic valve replacement: an alternative to the conventional technique

To demonstrate the use of minimally invasive surgery for aortic valve replacement and compare your results with the traditional method. Between 2006 and 2011 sixty patients underwent surgery on aortic valve, after written consent, these 40 by minimally invasive technique with right anterior minithoracotomy access (Group 1/G1) and 20 by median sternotomy (Group 2/G2). Compare the operating times and postoperative evolution intra-hospital. The average times of bypass and aortic crossclamp in G1 were, respectively, 142.7 ± 59.5 min and 88.6 ± 31.5 min and, in G2, 98.1 ± 39.1 min and 67.7 ± 26.2 min (P < 0.05), a difference in medians of 39 minutes in bypass time and 23 minutes in aortic cross-clamp were observed in favour of conventional technique. The blood loss by the thoracic drains was significantly lower in the Group: minimally invasive 605.1 ± 679.5 ml (G1) versus 1617 ± 1390 ml (G2) (P < 0.05).The average time of ICU and hospital stay were shorter in G1: 2.3 ± 1.8 and 5.5 ± 5.4 days versus 5.1 ± 3.6 and 10 ± 5.1 in G2 (P < 0.05), respectively. Vasoactive drug use was also less post-operative at 12.8% in minimally invasive group G1 versus 45% in G2. Aortic valve replacement through minimally invasive techniques, although intraoperative times larger, not demonstrate affect postoperative results that this case proved best when compared to the traditional approach.

Right minithoracotomy versus full sternotomy for the aortic valve replacement: Preliminary results

Minimally invasive surgery (MIS) for aortic valve replacement (AVR) is going to increase with different techniques described so far. We hereby report the results of AVR through a right minithoracotomy (RM) compared to a median sternotomy (MS). One hundred patients operated for isolated AVR by the same surgeon (chief of the department) were enrolled and allocated to: MS (group A, 50 patients, 26 females, mean age 69.9 ± 12.4 years). RM (group B, 50 patients, 27 females, mean age 71.6 ± 11.2 years). Mean logistic Euroscores were, respectively, 6.5 ± 4.0 and 8.0 ± 5.9 (p=ns). Mean duration of cardiopulmonary by-pass (CPB) was 62.8 ± 18.3 min in group A and 101.4 ± 35.2 min in group B (p<0.05); cross-clamp was 44.8 ± 13.4 min in group A and 74.6 ± 26.7 min in group B (p<0.05). Thirty-day mortality was 2 (4%) in group A and 0 in group B (p=ns). ICU stay and hospital stay did not significantly differ amongst two groups. The incidence of bleeding was lower in group B, showing a slight reduction of blood transfusions and re-explorations (p=ns). Our experience shows that RM offers a good 30-day survival and a lower incidence of mediastinitis or osteomyelitis. The risk of insufficient vision or sudden complications is safely managed by enlarging the surgical incision through a transverse sternotomy.

J-shaped versus median sternotomy for aortic valve replacement with minimal extracorporeal circuit

Objectives. Minimal access Aortic Valve Replacement (AVR) has been demonstrated to have beneficial effects over median sternotomy. Minimal extracorporeal circulation (MECC) has been shown to have less deleterious effects than conventional cardiopulmonary bypass. We describe for the first time AVR via upper J-shaped partial sternotomy compared to median sternotomy using MECC. Methods. Prospectively collected pre-operative, intra-operative, post-operative and follow-up data from 104 consecutive patients who underwent minimal access AVR were compared to 72 consecutive patients undergoing median sternotomy using MECC during the same period (January 2007 to December 2009). Results. No significant differences were found in patient's characteristics or intra-operative data with the exception of pre-existing pulmonary disease. The mean cardiopulmonary bypass (86 ± 18 min vs. 78 ± 15 min, p = 0.0079) and cross-clamp times (65 ± 13 min vs. 59 ± 12 min, p = 0.0013) were significantly shorter in the median sternotomy group. Mediastinal blood loss (397 ± 257 ml vs. 614 ± 339 ml, p < 0.0001) and ventilation time (8 ± 6.9 h vs. 11 ± 16.5 h, p = 0.0054) were significantly less in the minimal access group. No differences were seen in transfusion requirements, inotropic support, intensive care unit (ICU) stay, total hospital stay, post-operative haemoglobin drop, major events or mortality. Quality of life scores after discharge demonstrated less pain with a quicker recovery and return to daily activities in patients receiving J-shaped sternotomy. Conclusions. Minimal access AVR using MECC is feasible and provides excellent clinical results. Less pain and quicker recovery was experienced among patients in this group.

Outcomes of Right Minithoracotomy Mitral Valve Surgery in Patients With Previous Sternotomy

We evaluated the outcomes of patients with a history of previous sternotomy who underwent minimally invasive mitral valve surgery through a right minithoracotomy approach. We reviewed all the isolated mitral valve operations performed at our institution between January 1, 2005, and October 8, 2010, and selected for analysis only patients who had had a prior sternotomy. The outcome of patients who underwent a minimally invasive approach was compared with that of patients whose mitral surgery was performed through a standard median sternotomy. There were 88 patients with prior sternotomy, with 59 having minimally invasive surgery and 29 undergoing a repeat median sternotomy. Significant baseline differences (minimally invasive versus sternotomy, respectively) included the number of male patients (76% versus 45%, p=0.003), prior coronary artery bypass graft surgery (71% versus 45%, p=0.02), prior valve surgery (47% versus 72%, p=0.03), congestive heart failure (46% versus 76%, p=0.008), and diabetes mellitus (34% versus 10%, p=0.02). The in-hospital mortality and composite postoperative complications were 3% versus 14% (p=0.07) and 29% versus 66% (p=0.001) for the minimally invasive versus the median sternotomy group, respectively. The intensive care unit stay and hospital length of stay were 48 hours (interquartile range [IQR], 41 to 90) versus 118 hours (IQR, 67 to 167; p<0.001), and 8 days (IQR, 6 to 12) versus 13 days (IQR, 9 to 18; p=0.001), for the minimally invasive and median sternotomy groups, respectively. Minimally invasive mitral valve surgery in patients who have had a prior sternotomy is associated with improved postoperative outcomes and reduced resource utilization, when compared with a median sternotomy approach.

Outcomes of a Minimally Invasive Approach Compared With Median Sternotomy for the Excision of Benign Cardiac Masses

We hypothesize that for the excision of benign cardiac masses, a minimally invasive approach through a right minithoracotomy is safe and feasible, and has lower resource utilization when compared with a standard median sternotomy. We retrospectively analyzed 39 consecutive patients who underwent benign cardiac mass excision at our institution between December 1999 and April 2010. The in-hospital outcomes of patients who had a right minithoracotomy were compared with those of patients who underwent a standard median sternotomy. Of the 39 patients, 22 had cardiac masses removed through a minimally invasive approach, and 17 had a median sternotomy. The type of masses resected included 26 myxomas (66.7%), 9 papillary fibroelastomas (23.1%), and 4 thrombi (10.2%). The aortic cross-clamp and cardiopulmonary bypass times were 43 minutes (interquartile range [IQR] 30 to 64) versus 31 minutes (IQR 23 to 47; p=0.20) and 78 minutes (IQR 55 to 88) versus 57 minutes (IQR 33 to 70; p=0.02) for the minimally invasive group and the median sternotomy group, respectively. There were no significant differences in postoperative complications including mortality. The mean intensive care unit and hospital lengths of stay were 27 hours (IQR 24 to 47) versus 60 hours (IQR 48 to 79; p=0.001) and 5 days (IQR 4 to 6) versus 7 days (IQR 6 to 8; p=0.03) for the minimally invasive and the median sternotomy group, respectively. A minimally invasive approach through a right minithoracotomy for the resection of benign cardiac masses can be performed safely with lower resource utilization, and should be considered for these patients.

Outcomes of Minimally Invasive Valve Surgery Versus Standard Sternotomy in Obese Patients Undergoing Isolated Valve Surgery

We hypothesize that composite in-hospital surgical complications are lower in obese patients who undergo minimally invasive valve surgery for aortic and (or) mitral valve disease, when compared with the standard median sternotomy approach. We retrospectively reviewed 2,288 heart operations done at our institution between January 3, 2005 and January 10, 2010, and identified 160 consecutive obese patients, defined as patients with a body mass index of greater than 30 kg/m(2), who underwent isolated mitral and (or) aortic valve surgery. The outcomes of those who had minimally invasive valve surgery were compared with a matched control group who had valve surgery through a median sternotomy approach. Of the 160 patients, 64 underwent the minimally invasive approach and 96 had a median sternotomy. The mean age was 69.4 ± 11 years for the minimally invasive group, and 64.7 ± 11.5 for the median sternotomy group (p = 0.015). Composite postoperative complications occurred in 15 (23.49%) versus 49 (51.0%) patients (p = 0.034) in the minimally invasive group versus median sternotomy, respectively. The difference was driven by a lower incidence of acute renal failure (0 vs 6 patients [6.25%], p = 0.041), prolonged intubation (12 [18.7%] vs 33 [34.3%], p = 0.049), reintubation (3 [4.68%] vs 15 [15.6%], p = 0.032), deep wound infections (0 vs 4 [4.1%], p = 0.098), and death (0 vs 8 [8.3%], p = 0.041), respectively. All patients in the minimally invasive group were alive at 30 days. Minimally invasive surgery for isolated valve lesions in obese patients has a lower morbidity and mortality when compared with the standard median sternotomy approach.

Early Outcomes after Bilateral Thoracoscopy versus Median Sternotomy for Lung Volume Reduction

: A National Emphysema Treatment Trial subanalysis, although finally describing outcomes as "comparable," suggested that bilateral lung volume reduction surgery (LVRS) by video-assisted thoracoscopic surgery (VATS) may be slightly less morbid than by median sternotomy (MS). We report a single surgeon experience using both the MS and VATS approaches to provide additional information on this issue in a setting of uniform patient selection and perioperative management. Our hypothesis was that a VATS approach would provide equivalent or less morbidity than MS despite being applied to a group of patients subjectively selected to be higher risk than those undergoing MS. : Consecutive patients over a 9-year period underwent LVRS by one surgeon by either MS or VATS in a nonrandomized fashion. Thoracoscopy was selected over MS primarily when the surgeon estimated a greater overall risk profile and thus a greater chance of morbidity/mortality in a particular patient. : There were 15 patients in the VATS group and 35 in the MS group. In terms of measures of risk profile, there were no differences between the groups that met statistical significance, but several values trended toward higher risk within the VATS group (eg, age, 63 VATS vs. 59 MS, P = 0.08; moderate pulmonary hypertension, 38% VATS vs. 14% MS, P = 0.11; and residual volume, 241% VATS vs. 226% MS, P = 0.32). With regard to outcomes, operative time was significantly longer in the VATS group (VATS = 155 minutes vs. MS=129 minutes, P = 0.01). All other outcomes, including the incidence of major complications (13.3% VATS vs. 17.1% MS, P = 0.39), were similar between the groups. There was a single death within 90 days (1.9% of entire series; 2.9% of MS group). : In this series, although patients undergoing LVRS by VATS tended to have a higher risk profile, their outcomes were no worse than in those undergoing LVRS by MS. This suggests that the VATS approach to bilateral LVRS may incur slightly less morbidity and thus may be the best option in the most compromised patients who is nonetheless felt will benefit from LVRS.

CT findings of post-pneumonectomy patients

CT findings following pneumonectomy were studied in 28 cases with lung cancer. A total of 53 CT images were evaluated in 13 right pneumonectomy cases and 15 left pneumonectomy patients. The postpneumonectomy pleural space (PS), thoracic space of the operated site (TS) and the thoracic space of the non-operated site (CTS) were measured at 3 slice levels of the brachiocephalic level, subcarinal level and lower pulmonary vein level, using a digital planimeter. There was no significant difference in the TS/CTS ratio, between the right pneumonectomy group and the left pneumonectomy group, but the PS/TS ratio in the left pneumonectomy group was smaller than that in the right pneumonectomy group (p less than 0.01). The PS/TS ratio in both groups and the TS/CTS ratio in the right pneumonectomy group were decreased with time. In the left pneumonectomy group, the TS/CTS ratio was greater in the median sternotomy group that of the posterolateral thoracotomy group (p less than 0.01). Residual pleural effusion was accompanied with a thin circulating lesion along the outer surface. This lesion had been reported as thickening of the parietal pleura, but it could be detected in the case of panpleuropneumonectomized state. Additionally, in some cases, the parietal pleural imaging could be separated from the circulating lesion. So, this structure was thought to be mainly composed of organized effusion. CT images could detect some parts of the episodes in post operated thorax, because of the lack of the information with the sagittal direction. However, the recognition of the common changes and images on CT after the operation might be helpful for the follow-up of the patients.

Quality of mitral valve repair: Median sternotomy versus port-access approach

We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches. Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques. Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11). In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach.

Staphylococcus aureus mediastinitis and sternal osteomyelitis following median sternotomy in a rat model

Median sternotomy (MS) wound infections are severe complications causing high morbidity and mortality after cardiac surgery. We aimed to develop a new Staphylococcus aureus mediastinitis and sternal osteomyelitis model in rats that can be used to evaluate the efficacy of new antimicrobial treatments. A complete MS wound was induced in anaesthetized rats. S. aureus was injected into the sternum. Kinetics of bacterial growth in the sternum (10(7) cfu/sternum) was assessed for histopathology and bacterial counts. A non-infected MS group served as a control. To evaluate antibiotic efficacy, 5 days of intraperitoneal vancomycin therapy (50 mg/kg, twice a day) was initiated 24 h following bacterial challenge. Macroscopic and histological examination confirmed that infection resulted in sternitis and mediastinitis. S. aureus bacterial counts in the sternum were inoculum-dependent, and it was proven that infecting rats with an inoculum of 10(7) cfu/sternum induced mediastinitis and sternal osteomyelitis. At this inoculum, bacterial counts in the infected sternum increased with time, reaching a maximum level of 2 +/- 1 x 10(7) cfu/g of sternum 8-12 days post-infection and then decreased with time to 2 x 10(4) cfu/g of sternum 20 days after infection. Histological changes paralleled bacterial counts. Vancomycin administration showed a protective effect against induction of sternal osteomyelitis; sternums from vancomycin-treated rats showed a significant decrease in S. aureus counts by 0.72 +/- 0.35 log cfu/g compared with untreated controls (P = 0.0162). This new rat model of S. aureus sternal osteomyelitis and mediastinitis allows quantitative measurement of bacterial counts in the sternum. This model is reproducible and simple and thus suitable for the evaluation of new antimicrobials and new treatment modalities in MS infections.