Median Sternotomy In Patients Research Articles

Rigid Sternal Fixation and Enhanced Recovery for Opioid-Free Analgesia After Cardiac Surgery

BackgroundWe evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice. MethodsThis single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent operation before implementation of RPF or ERP (“controls”), patients closed with RPF before ERP implementation (“RPF-only”), and patients managed with RPF and ERP during early “RPF+ERP-2020” and late “RPF+ERP-2022” implementation. ResultsThe analysis included 608 median sternotomy patients (mean age, 65.7 ± 10.8 years; 29.6% women). Of those, 59.2% were isolated coronary artery bypass grafting, 7.7% were isolated valve procedures, and the rest were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents (MMEs) in the control cohort vs 0 MMEs for RPF+ERP-2022 (P < .0001), despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls, 79.6% for RPF-only (P = .010), and 93.5% for RPF+ERP-2022 (P < .0001). Median opioids prescribed at discharge were 600 MMEs for controls and 0 for RPF+ERP-2020 and RPF+ERP-2022 (P < .0001). At discharge, 86.7% of RPF-only patients received prescription opioids vs 5% in RPF+ERP-2020 and 4.3% RPF+ERP-2022 (P < .0001). These outcomes occurred without increased readmissions. ConclusionsSystematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population.

Novel use of interosseous absorbable mattress sutures for secondary sternal fixation: A case series

There is currently no consensus on the treatment of median sternotomy patients presenting secondarily with deep sternal wound infection or symptomatic sternal nonunion. We have developed a novel approach to sternal bone fixation when concerns for open wounds or microbial colonization preclude the use of permanent hardware placement: (1) sternal closure with absorbable interosseous monocortical horizontal mattress sutures followed by (2) multilayered soft tissue closure with pectoralis major advancement or turnover flaps. Benefits of this technique include: closure of retrosternal dead-space, tension offloading of the soft tissue closure, repair of transverse sternal fractures, and preservation of internal mammary artery (IMA) perforators for potential pectoralis turnover flaps. In our early experience, this technique has been successful at promoting functional sternal union - even in secondary closure of high-risk patients contraindicated for permanent hardware placement.

THORACOSCOPY VERSUS STERNOTOMY IN THE CORRECTION OF A VENTRICULAR SEPTAL DEFECT: A SINGLE CENTER EXPERIENCE

Objective: To compare the immediate outcomes of thoracoscopy and median sternotomy in patients undergoing ventricular septal defect repair. Materials and мethods. We analyzed 59 patients diagnosed with VSD who were operated on at the SCCCST from 2012 to 2021. All patients were divided into two groups: group 1 included patients in whom thoracoscopic access was used (n=27), group 2 included the method of complete median sternotomy (n=32). Results. There were no statistically significant differences in complications in the postoperative period and no in-hospital mortality. The duration of the procedure and the duration of cardiopulmonary bypass in the thoracoscopy group were longer than in the sternotomy group. Blood loss during and after surgery was lower in the thoracoscopy group than in the sternotomy group. Hence, less blood and plasma transfusion was required in the thoracoscopy group than in the sternotomy group. The length of stay in the intensive care unit, the time spent on mechanical ventilation, bed days after surgery, the use of analgesics were statistically lower in the thoracoscopy group than in the sternotomy group. It should be noted that the length of the skin incision in patients in the thoracoscopy group was significantly less than in the second group. Conclusion. Thoracoscopic approach for VSD correction is an effective and low-traumatic method that does not increase the risk of surgical complications. Routine use of this technique requires a study on a larger sample of patients.

The effect of platelet-rich plasma on sternal healing postmedian sternotomy in patients undergoing open heart surgery

Background Plasma is the fluid portion of blood which contains clotting factors, other proteins, and ions. Platelet-rich plasma (PRP) is defined as a volume of the plasma fraction of autologous blood with many more platelets than what is typically found in blood. The concentration of platelets and thereby the concentration of growth factors (GFs) can be 5 to 10 times greater (or richer) than usual. The aim of this study is to evaluate the effect of PRP on sternal healing post median sternotomy in patients undergoing cardiac surgery. Patients and methods A single-center, prospective, comparative study. We recruited 100 patients who were referred for open heart surgery, through median sternotomy, to our Cardiothoracic Surgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt between March 2020 and January 2022. Patients were divided into two equal groups; the study group where we applied topical autologous PRP to the sternal edges before sternal closure, and the control group who did not receive PRP. Results The two groups were similar in their demographics. We found no significant benefit in terms of sternal healing between the two groups assessed by measuring bone density. Superficial and deep wound infections were similar in both groups; however, we found a marked reduction in blood loss in patients who received PRP (group 1) compared with control group (group 2). Conclusion Applying PRP topically to the sternal edges following median sternotomy did not improve sternal healing of the incidence of superficial or deep sternal wound infection. It may be beneficial in reducing blood loss from the sternal edges and hence blood transfusion requirement following surgery.

Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair

A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.

Perioperative Hemodynamics And Right Ventricular Performance During Lvad Implantation Via Median Sternotomy V. Lateral Thoracotomy.

Background : Perioperative right ventricular dysfunction (RVD) is common during implantation of a left ventricular assist device (LVAD). While an LVAD may be implanted via median sternotomy (MS) or lateral thoracotomy (LT), data comparing hemodynamics during these surgical approaches are sparse. Methods : Twenty-one patients with advanced heart failure were randomized in a 1:1 fashion to undergo LVAD implantation via MS v. LT. Cardiovascular hemodynamics and RV function were simultaneously measured via Swan-Ganz catheterization and conductance catheters for real-time RV pressure-volume (PV) analysis. Data were collected at three timepoints: 1) Baseline immediately before surgery; 2) Postoperative Day 0 in the intensive care unit (ICU); and 3) Postoperative Day 1 in the ICU. Results : Baseline characteristics are displayed in Table 1. LVAD was implanted via MS v. LT in ten v. eleven patients, respectively. Sixteen patients received a Heartware VAD and five received a Heartmate 3 LVAD. Right atrial and mean pulmonary arterial pressures declined over time for patients undergoing LVAD implantation via LT but increased in response to MS (Figure 1). RV stroke volume and cardiac output were higher on postoperative day 1 among LT v. MS patients (Figure 1, Table 2). Other metrics of RV performance, determined by RV PV analysis, were similar between groups (Table 2). Conclusion : In this pilot analysis, LVAD implantation via LT may be associated with more favorable perioperative cardiovascular hemodynamics and RV contractility than MS. Further analysis is necessary to determine differences in longterm outcomes. : Perioperative right ventricular dysfunction (RVD) is common during implantation of a left ventricular assist device (LVAD). While an LVAD may be implanted via median sternotomy (MS) or lateral thoracotomy (LT), data comparing hemodynamics during these surgical approaches are sparse. : Twenty-one patients with advanced heart failure were randomized in a 1:1 fashion to undergo LVAD implantation via MS v. LT. Cardiovascular hemodynamics and RV function were simultaneously measured via Swan-Ganz catheterization and conductance catheters for real-time RV pressure-volume (PV) analysis. Data were collected at three timepoints: 1) Baseline immediately before surgery; 2) Postoperative Day 0 in the intensive care unit (ICU); and 3) Postoperative Day 1 in the ICU. : Baseline characteristics are displayed in Table 1. LVAD was implanted via MS v. LT in ten v. eleven patients, respectively. Sixteen patients received a Heartware VAD and five received a Heartmate 3 LVAD. Right atrial and mean pulmonary arterial pressures declined over time for patients undergoing LVAD implantation via LT but increased in response to MS (Figure 1). RV stroke volume and cardiac output were higher on postoperative day 1 among LT v. MS patients (Figure 1, Table 2). Other metrics of RV performance, determined by RV PV analysis, were similar between groups (Table 2). : In this pilot analysis, LVAD implantation via LT may be associated with more favorable perioperative cardiovascular hemodynamics and RV contractility than MS. Further analysis is necessary to determine differences in longterm outcomes.

Hemodynamic Response and Periprocedural Right Ventricular Function During a Lateral Thoracotomy versus Median Sternotomy Surgical Approach to Implantation of a Left Ventricular Assist Device - A Pilot Study

<h3>Purpose</h3> While continuous-flow LVADs improve survival in patients with advanced heart failure, right ventricular dysfunction continues to be a significant clinical challenge. Lateral thoracotomy implantation of LVADs has been postulated to reduce right ventricular failure, and the need for RVAD support, but recently published reports are conflicting. However, data regarding the impact of implantation technique on perioperative right ventricular hemodynamics are lacking. <h3>Methods</h3> Twenty-one patients were randomized to receive LVAD implantation via median sternotomy (MS) or lateral thoracotomy (LT). All implants were performed on cardiopulmonary bypass (CPB), and patients were weaned from CPB per institutional practice. In addition to standard perioperative hemodynamic monitoring, we placed a conductance catheter into the right ventricle to monitor the pressure-volume relationship in the perioperative period. <h3>Results</h3> Mean pulmonary artery pressures declined for both patient groups, while right atrial pressure increased from baseline to post-operative day 1 (POD1) in the MS group but decreased in the LT group. Among MS patients, metrics of contractility (stroke work and pressure volume area) decreased in the immediate perioperative period but returned to baseline by POD1. In the LT group, metrics of contractility were similar or increased from baseline on POD1. <h3>Conclusion</h3> In this pilot analysis, thoracotomy implantation of LVADs was associated with improved right ventricular function in the perioperative period. The more favorable hemodynamics in the LT group provide insight into the physiological mechanism by which right ventricular dysfunction is reduced in other clinical reports.

Minimally invasive mitral valve repair for degenerative etiology: a comparative study

BackgroundThere is a paucity of data comparing the minimally invasive mitral valve repair (MiMVr) to the conventional approach in patients with degenerative disease. Our objective was to compare the outcomes of MiMVr to the traditional mitral valve repair through median sternotomy in patients with degenerative mitral valve disease. We conducted a retrospective study on 215 patients classified into two groups. Group 1 (n = 80) included those who had mitral valve repair through a right anterolateral video-assisted mini-thoracotomy, and group 2 (n = 135) was approached through a conventional median sternotomy. We compared the preoperative, operative, and postoperative data between groups. Both groups had echocardiographic follow-ups after 6 and 12 months.ResultsThere was no difference in gender distribution between both groups, and patients who had median sternotomy were significantly older (median 37 (Q1-Q3, 29-44) vs. 54 (48-60) years; P < 0.001). Cardiopulmonary bypass (134.5 (130-138.5) vs. 99 (97-104) min; P < 0.001) and ischemic times (99 (95-105.5) vs. 78 (75-81) min; P < 0.001) were significantly shorter in patients who had median sternotomy. Patients with MiMVr had significantly lower blood loss (370 (315-390) vs. 550 (490-600) ml; P < 0.001) and ICU stay (5 (4.5-6) vs. 7 (7-8) days; P < 0.001). There was no difference between both groups regarding re-exploration for bleeding, postoperative stroke, wound infection, renal failure, and mortality. As regards postoperative echocardiography follow-up at 6 and 12 months after the operation, there were no significant changes in the mean mitral valve gradient within each group; however, the mean gradient was lower in the MiMVr group (3 (3-3.5) vs. 4 (3-5) mmHg; P < 0.001). There was no significant difference between both groups regarding mitral regurgitation severity during 6 and 12 months follow-up.ConclusionMinimally invasive mitral valve repair in patients with degenerative pathology could be an alternative to conventional mitral valve surgery with comparable short-term and long-term outcomes.

PREVALENCE OF MUSCULOSKELETAL PAIN IN PATIENTS WHO UNDERWENT MEDIAN STERNOTOMY-A CROSS SECTIONAL SURVEY

Background: One third of post patients experience moderate to severe chronic nonanginal postoperative pain (CPOP) and its management remains a challenge despite modern pharmaceutical preparations and new invasive and non-invasive pain –allaying techniques. Physiotherapy plays a major role in cardio-thoracic rehabilitation from the pre-operative period to postoperative period. Cardiac Rehabilitation is a medically supervised program that helps to improve the health and social well-being of people.&#x0D; Objective: The aim of the study is to investigate the prevalence of musculoskeletal pain in patients who underwent cardio-thoracic surgery. PROCEDURE: Study design was non-experimental and study type was observational. 53 patients who satisfied the inclusion and exclusion criteria were selected conveniently for the study after obtaining informed consent. Nordic questionnaire is used as an outcome measure to identify the pain in post-operative patients.&#x0D; Results: Highest pain was reported in upper back (94.3)% region followed by shoulder (37.7)%lower back (26.4)% and neck (24.5)%, region when patients were assessed on 7th post-operative day by using Nordic questionnaire.&#x0D; Conclusion: This study concludes that there was a prevalence of upper back pain when compare to other regions and has showed the least prevalence of pain in elbow, wrist and hand.&#x0D; Keywords: Median sternotomy patients, Musculoskeletal pain, Nordic questionnaire.

COMPARISON OF INCIDENCE OF STERNAL WOUND DEHISCENCE AFTER SIMPLE INTERRUPTED STERNAL CLOSURE VS FIGURE-OF-EIGHT STERNAL CLOSURE IN PATIENTS OF CORONARY ARTERY BYPASS GRAFT SURGERY

Objective: To compare the incidence of sternal wound dehiscence between simple interrupted vs. figure-of-eight sternal closure techniques for median sternotomy in patients undergoing coronary artery bypass graft surgery.&#x0D; Study Design: Comparative prospective, randomized control trial.&#x0D; Place and Duration of Study: Study conducted at Department of Cardiac Surgery, Armed Forces Institute of Cardiology Rawalpindi, from Apr to Dec 2019.&#x0D; Methodology: A total of 206 patients were included in study. These patients were divided into two groups; group “A”: cases which will undergo simple interrupted sternal wire closure technique (n1=103). Group “B”: cases which will undergo figure-of-eight sternal wire closure technique (n2 = 103).&#x0D; Results: There were no statistical difference in the pre-operative data of the patients. The incidence of sternal wound dehiscence in simple interrupted closure was 6.79% while in figure of eight closure technique it was noted to be 1.94%. A statistically significant difference was noted in both the closure technique (p&lt;0.05).&#x0D; Conclusions: Figure-of-eight sternal wire closure technique provides better strength and stability to sternum along with reduced incidence of sternal wound dehiscence as compare to simple interrupted wire closure.

Early Outcome of Minimally Invasive Versus Median Sternotomy Mitral Valve Replacement In Patients With Severe Chronic Obstructive Pulmonary Disease

Background: Minimally invasive valve surgery is considered much more beneficial than routine median sternotomy in patients undergoing open heart surgery with sever chronic obstructive pulmonary disease (COPD). Objective: To compare between early outcomes of minimally invasive versus routine median sternotomy in patients with severe COPD undergoing isolated mitral valve replacement (MVR). Patients and Methods: 100 patients with severe COPD between October 2016 and September 2019 underwent isolated MVR. Patients were divided into 2 groups: Group (A): 50 patients underwent surgery via minimally invasive approach and group (B): 50 patients underwent surgery via median sternotomy. Early postoperative complications, Intensive Care Unit stay and total hospital stay were compared in both groups. Results: The mean age was 60 ± 9 years for Group (A) and 61 ± 10 years for Group (B), (P = 0.29). Combined postoperative complications were significantly lower in Group (A) [8 (16%) versus 12 (24%), P < 0.05]. The median postoperative mechanical ventilation time was 10 hours in group (A) versus 22 hours in group (B) (P < 0.05). The median ICU stay in group (A) was 1.5 days versus 3 days in group (B) (P < 0.05). The median length of total hospital stay was 7 days in group (A) versus 13 days in group (B) (P < 0.05). The overall hospital mortality was 2 patients (4%) in group (A) versus 1 patient (2%) in group (B) P < 0.05. Conclusion: Minimally invasive had better early outcome than routine median sternotomy in patients with severe COPD undergoing MVR and should be considered as a good option in these patients.

Early Outcome of Minimally Invasive Versus Median Sternotomy Mitral Valve Replacement In Patients With Severe Chronic Obstructive Pulmonary Disease

Minimally invasive valve surgery is considered much more beneficial than routine median sternotomy in patients undergoing open heart surgery with sever chronic obstructive pulmonary disease (COPD).

Statin treatment and hypertrophic scarring after cardiac surgery.

Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid-lowering effects, statins are known for their pleiotropic and anti-inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P = .001) and nonstatin users (P = .001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29-0.53, P = .001), after adjustment for age. A dose-dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose-dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti-scarring agents is novel and should be investigated with tailored studies.

Early and long-term clinical outcomes after minimally invasive direct coronary artery bypass grafting versus off-pump coronary surgery via sternotomy in isolated proximal left anterior descending artery disease: A propensity score matching analysis.

This study was designed to compare short-term and long-term clinical outcomes of minimally invasive direct coronary artery bypass (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB) via median sternotomy in patients with single-vessel left anterior descending (LAD) arterydisease. In this retrospective study, 194-patients met the inclusion criteria and were divided into the MIDCAB group (n = 111) and OPCAB via median sternotomy group (n = 83). Short-term outcomes included: in-hospital mortality, perioperative myocardial infarction (MI), perioperative cerebrovascular adverse events (CAEs), chest drainage, reoperation for bleeding, duration of surgery, ventilation time, deep wound infection, packed red blood cell (pRBC) transfusion and duration of hospital stay. The long-term outcomes included: all-cause mortality, the incidence of MI and stroke, target vessel revascularization (TVR) and composite of mortality/MI/stroke. Propensity score matching (PSM) was used to match patients between the groups. Before as well as after the PSM, no significant differences were observed between both groups in terms of in-hospital mortality, incidence of perioperative MI, incidence of CAEs, reoperation for bleeding, pRBC transfusions, deep wound infection and ventilation time. However, MIDCAB group had lower chest tube drainage and shorter hospital stay. On the other hand, OPCAB group had shorter time of surgery before as well as after PS matching. At 7-years, before and after PSM, freedom from all-cause mortality, MI, stroke, TVR as well as composite of mortality/MI/stroke were comparable between both groups. Short-term as well as long-term outcomes of MIDCAB in terms of mortality, MI, stroke, and target vessel revascularization are satisfactory and as safe and effective as OPCAB via sternotomy.

Efficacy of Intravenous Acetaminophen as Adjunct Post-Operative Analgesic in Cardiac Surgery: A Retrospective Study

The dose-dependent adverse events associated with post-operative opioid use may be reduced when opioids are used in conjunction with intravenous acetaminophen. The purpose of this study was to compare outcomes in median sternotomy patients receiving intravenous acetaminophen in addition to intravenous opioids versus intravenous opioids only. A retrospective study was conducted on 122 adult patients undergoing median sternotomy at a regional tertiary-referral center. Data collected included patient demographics, length of stay, opioid and intravenous acetaminophen use, adverse effects, and transition time to oral pain medication. There was no difference between groups in demographics, preoperative risk scores, operative procedures, intravenous opioid consumption, transition time to oral pain medications, or length of stay. Acetaminophen use was associated with lower rates of atrial fibrillation (7.0% vs. 24.6%, p = 0.009) and nausea/vomiting (8.9% vs. 32.3%, p = 0.002), but higher rates of urinary retention (15.8% vs. 3.1%, p = 0.014), constipation (50.0% vs. 20.0%, p = 0.001) and respiratory depression (7.1% vs. 0.0%, p = 0.043). Intravenous acetaminophen was not associated with a reduction in length of stay or opioid consumption, but was associated with lower rates of atrial fibrillation, nausea, and vomiting. Additional studies are needed to determine if intravenous acetaminophen administration reduces atrial fibrillation in this population.

Minithoracotomy vs. Conventional Mitral Valve Surgery for Rheumatic Mitral Valve Stenosis: a Single-Center Analysis of 128 Patients.

ObjectiveTo compare the in-hospital outcomes of a right-sided anterolateral minithoracotomy with those of median sternotomy in patients who received a mitral valve replacement (MVR) because of rheumatic mitral valve stenosis (RMS).MethodsThis is a retrospective analysis of 128 patients (34% male) with RMS between 2011 and 2015. The median age was 53 years (45; 56). The mean ejection fraction was 58.4±6.3%. All the subjects were divided into two groups - Group 1 contained 78 patients who underwent MVR via minithoracotomy (MT-MVR), while Group 2 contained 50 patients who underwent MVR via median sternotomy (S-MVR).ResultsIn the MT-MVR group, a mechanical prosthesis was implanted in 72% of cases, while it was implanted in 90% of cases in the S-MVR group (P=0.01). The duration of myocardial ischemia was similar (MT-MVR, 77±24 min; S-MVR, 70±18 min) (P=0.09). However, the cardiopulmonary bypass time was lower in the S-MVR group than in the MT-MVR group (99±24 min and 119±34 min, respectively) (P≤0.001). There was no difference in the duration of mechanical ventilation, intensive care unit stay, and hospitalization period. Postoperative blood loss was lower in the MT-MVR group (P≤0.001) than in the S-MVR group. There are no statistically significant differences in postoperative complications (superficial wound infection, stroke, delirium, pericardial tamponade, pleural puncture, acute kidney insufficiency, and implantation of pacemaker). The overall in-hospital mortality was 3.9% (P=0.6)ConclusionThe minimally invasive approach for RMS is feasible and has an excellent cosmetic effect without increasing the risk of surgical complications.

Comparison of initial outcomes between minimally invasive right minithoracotomy and standard median sternotomy in patients undergoing isolated surgical closures of atrial septal defects.

Background: An atrial septal defect (ASD) can be closed via percutaneous approach and with surgical closure using either the standard median sternotomy or a minimally invasive procedure such as minithoracotmy. In this study, we evaluated the outcomes of using the median sternotomy versus the right minithoracotomy in isolated closures of ASDs. Methods: This prospective observational study included 44 patients who underwent isolated ASD closures in the department of cardiac surgery at the National Heart Foundation Hospital and Research Institute (NHFH & RI) in Dhaka, Bangladesh, from July 2014 to June 2016. After fulfilling the enrolment criteria, participants were divided into two equal groups of 22 patients. ASD closure was performed on Group 1 using the minimally invasive right minithoracotomy, while the same procedure was performed on Group 2 using the standard median sternotomy. Results: The mean total operative time (in minutes) required was 179.45 ? 26.79 for Group 1 and 154.72 ? 26.15 for Group 2. The mean aortic cross-clamp (ACC) time (in minutes) and cardiopulmonary bypass (CPB) time (in minutes) were significantly increased in Group 1 compared to Group 2 (p=<0.05). Furthermore, the mean ? SD of the length of incision (in centimetres) and duration of endotracheal intubation (in hours) were significantly higher in Group 2 than Group 1 (p<0.001). While the duration of postoperative hospital stays (in days) and pain score (visual analogue scale score) was significantly higher in Group 2 than Group 1. No residual shunt was found in patients of either group. Conclusion: Our findings shows some advantages in group 1 (right minithoracotomy) population including the reduced length of incision, the shorter duration of endotracheal intubation, less postoperative blood loss, fewer transfusion requirements, minimal postoperative pain and the shorter duration of hospital stay. In addition, patients in Group 1 reported smaller scars, as expected, which contributes to better overall patient satisfaction.

Lifesaving Emergency Sternotomy in Traumatic Cardiac Tamponade in a Teaching Hospital in Ghana: Survival of Two Rare Cases

Introduction: Patients presenting with cardiac injuries from gunshot wounds and blunt chest trauma have high mortality, without any observed survival benefit when presenting with cardiac tamponade. Cardiac tamponade is a life-threatening hemodynamically significant compression of the heart by a sudden or gradual accumulation of collections in the pericardial space that incites and overrides the body’s compensatory mechanism. Clinical Case: We present and discuss the successful management and survival of two patients with traumatic cardiac tamponade from gunshot wounds to the precordium who underwent successful lifesaving median sternotomy at a Teaching Hospital in Ghana with a new Cardiovascular and Thoracic Surgery Unit. Discussion: Usually the diagnosis of cardiac tamponade from traumatic haemopericardium is made by clinical findings which though may not always be present especially after blunt chest trauma. EFAST is a reliable tool for diagnosing and following cardiac tamponade. Median sternotomy is the standard procedure in these patients to access and repair cardiac injury either with or without cardiopulmonary bypass. Conclusion: Emergency median sternotomy in patients with cardiac tamponade from chest trauma especially after EFAST diagnosis can be lifesaving even in less resourced centres.

Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis.

Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS versus MS. Online databases Medline, EMBASE, Cochrane Library and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta or aortic arch surgery by MIS versus MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1101 MIS and 1405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS [standardized mean difference 0.36, 95% confidence interval (CI) 0.15-0.58; P = 0.001]. Patients receiving MS spent more time in hospital (standardized mean difference 0.30, 95% CI 0.17-0.43; P < 0.001) and intensive care (standardized mean difference 0.17, 95% CI 0.06-0.27; P < 0.001). Reoperation for bleeding (risk ratio 1.51, 95% CI 1.06-2.17; P = 0.024) and renal impairment (risk ratio 1.97, 95% CI 1.12-3.46; P = 0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.

Does using Jackson-Pratt drain affect the incidence of sternal wound complications after open cardiac surgery?

TThis study aims to investigate the effect of the Jackson-Pratt drain on sternal wound complications in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery via median sternotomy. A total of 174 patients (124 males, 50 females; mean age 58.2±10.4 years; range, 33 to 78 years) with a Body Mass Index of ≥30 kg/m2 undergoing cardiac surgery via median sternotomy between January 2011 and December 2015 in our institution were retrospectively analyzed. Of the patients, 94 were inserted a Jackson-Pratt drain (JP group) following median sternotomy, while 80 patients received no drain (non-JP group). Pre-, intra, and postoperative outcomes of both groups including type of operation, length of hospital stay, and complications were compared. No significant difference in the age, gender, Body Mass Index, and potential risk factors was found between the groups. The median of stay in the intensive care unit was two days and the median time from operation to discharge was seven days in both groups. There was a statistically significant difference in the rate of sternal wound complications between the groups. Sternal wound complications occurred in two patients (2.1%) in the drained group, compared to nine patients (11.25%) in the non-drained group (p=0.01). Our study results show that Jackson-Pratt drain insertion after median sternotomy in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery is a simple and reliable method to reduce the risk of postoperative sternal wound complications, compared to the conventional closure technique.