Median Sternotomy Incision Research Articles

Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for acute type A aortic dissection

Conclusion: In patients with acute type A dissection primary repair of the aorta that includes the aortic arch and the descending thoracic aorta can be performed in a single stage with a combination of standard synthetic grafts and self expanding stent grafts. Summary: Acute type A dissection of the aorta frequently necessitates emergent surgical treatment. This treatment is often limited to the region of the ascending aorta and aortic arch leaving a false lumen distally that can expand and/or rupture. In this paper the authors describe 35 subjects who received aortic arch replacement and treatment of the descending thoracic aorta using a combination of a synthetic graft for replacement of the aortic arch and a stent graft for treatment of the descending thoracic aorta. The patients were treated between December 1997, and April 2002. There was a mean followup of 55 months (range, 30-83 months). CT scans were performed at 1, 3, 12, and 36 months postoperatively in an effort to document obliteration of the false lumen and exclusion by the stent graft. Two patients died at the initial procedure secondary to bleeding and/or low cardiac output. The mean cardio pulmonary bypass time was 175 ± 41 minutes and mean operative time was 338 ± 86 minutes. There were 13 men and 22 women with a mean age of 67.8 years (range 47-80 years). The aortic arch was reconstructed under conditions of hypothermic circulatory arrest with re-implantation of the innominate artery, the left common carotid artery and left subclavian artery using synthetic grafts. Distally, a stent graft was placed in a 30 French introducer and inserted into the true lumen of the decending thoracic aortia via the median sternotomy incision. The graft was fixed in the true lumen of the descending aorta by expansion of the Z stent and aortic blood pressure. Proximally, the stent graft was sewn to the dital end of the aortic arch replacement. The mean diameter of the stent grafts was 26.2mm. The mean length of the stent grafts was 8.9cm. The technique resulted in obliteration of the false lumen at the distal edge of the graft in all patients. False lumen obliteration was also achieved in 65% of the patients at the diaphragmatic level and in 48% of the patients at the SMA level. Mean enlargement of the whole aorta at the level of the SMA from 1-36 months postoperatively was 0.375mm (range, 0-2mm). Mean enlargement of the entire aorta at the level of the diaphram from 1-36 months postoperatively was only (0.5mm range, 0-2mm). Paraplegia and intestinal ischemia did not occur. No patients required additional surgical treatment of the thoracoabdominal aorta after discharge from the hospital. Comment: This is a clever use of the combination of endovascular and open surgery. It is essentially a 1-step elephant trunk procedure. The technique appears to represent a significant advance over 2-stage open repair of type A aortic dissection. Hopefully this approach can significantly reduce the number of patients requiring late descending thoracic aortic repair following repair of type A dissection.

Definitive Closure of the Infected Median Sternotomy Wound

Mediastinitis and sternal wound dehiscence are devastating and life-threatening complications of median sternotomy incision. Ten consecutive patients between July 2001 and May 2005 were diagnosed with sternal wound infection and dehiscence following median sternotomy. Patients were managed by precise debridement and wound excision in the operating room and then dressed with vacuum-assisted closure device. Intravenous antibiotics were prescribed for wound and blood culture microbiological sensitivity. When wounds were bacteriologically controlled, patients returned to the operating room for definitive closure using rigid sternal plating. All patients were extubated postoperatively. No patients died. Average total hospital stay was 21 days. The pectoralis advancement flap was exclusively used for soft tissue reconstruction in 7 patients. There were 2 cases of chronic superficial sternal infection requiring plate removal; however, bony union of the sternum was achieved in all patients. This treatment algorithm provides a useful management strategy for patients with complicated median sternotomy.

Right Atrial Perforation Resulting From Pulmonary Artery Catheter Insertion During Coronary Artery Bypass Surgery

An 84-year-old man presenting with triple-vessel coronary artery disease and unstable angina pectoris associated with mitral valve stenosis was scheduled for coronary artery bypass graft surgery and mitral valve replacement. His medical history was significant for chronic pulmonary obstructive disease and moderate left ventricular dysfunction, thus warranting the use of a PAC for the accurate monitoring of hemodynamic parameters. Although transesophageal echocardiography has been widely used during cardiac surgery, the use of a PAC is still an alternative when TEE is not available in the operating room. The patient was premedicated with a combination of midazolam, 5 mg, and fentanyl, 50 g, intravenously, 30 minutes before surgery. PAC insertion was performed by using a modified Seldinger technique. The right internal jugular vein was punctured with a 22-G seeker needle at the angle formed by the bellies of the sternocleidomastoid muscle near the level of the cricoid cartilage. The vessel was cannulated with an 18-G straight introducer needle to a depth of 2 to 3 cm. Dark, nonpulsatile venous blood was obtained by aspiration during needle placement. A J-tip wire guide was inserted through the needle without difficulty, and an 8.5F introducer sheath of the PAC was placed over a dilator, which was introduced to its full length. Once again dark, nonpulsatile venous blood was easily aspirated from the sheath. A 7.5F PAC (model 831F75, Baxter Edwards, Irvine, CA) was inserted via the introducer into the right internal jugular vein. The balloon had been previously checked for proper inflation over the end of the catheter. After the insertion of 25 cm of the PAC with the balloon inflated, a significant resistance to pass the catheter into the RV was experienced. After several attempts that took about 5 minutes and without taking any additional measures, the catheter was successfully introduced into the right ventricle and then into the pulmonary artery, as assessed by the corresponding pressure waves. The final position of the catheter was at about 50 cm of insertion. There were no significant alterations in hemodynamic parameters or in electrocardiographic tracings during the wire guide or PAC insertion. General anesthesia was induced by using a combination of fentanyl, 300 g, and etomidate, 10 mg; pancuronium, 6 mg, was used for neuromuscular blockade. Anesthesia was maintained with isoflurane, 1.5% to 2% in oxygen. The chest was opened with a median sternotomy incision. After opening the pericardium, the presence of blood within the pericardial sac led to the identification of a perforation in the right atrium. It was an elliptically-shaped perforation with about 1 mm of diameter in the inferior portion of the atrial lateral wall, about 2 to 3 cm from the superior vena cava junction. The perforation was then sutured, and the patient underwent coronary artery bypass graft surgery without presenting further complications. Recovery was uneventful, and the patient was discharged 10 days after surgery with no residual complications.

Incisional herniae following median sternotomy incisions: their incidence and aetiology.

A retrospective study was carried out of all patients undergoing cardiothoracic surgery through a median sternotomy incision under the care of a single surgical firm over an 8 year period in order to assess the incidence and aetiology of incisional epigastric herniae. Of the 582 procedures carried out, follow-up information was obtained in 475 (81.6 per cent) of which 20 (4.2 per cent) had developed incisional herniae (70 per cent of these within 3 months). Seven (35 per cent) of the herniae were symptomatic and required repair. The main predisposing factors were the male sex, the nature of surgery carried out (notably aortic valve replacement), obesity and the presence of postoperative complications of wound infection and left ventricular failure. Herniae were not found in those patients having wound closure using non-absorbable sutures.

Off-Pump Ascending to Descending Aorta Bypass Grafting with Descending Aneurysm Exclusion

We performed an ascending to descending aorta bypass grafting with exclusion of the descending thoracic aortic aneurysm through a median sternotomy incision without cardiopulmonary bypass in a patient with severe chronic obstructive pulmonary disease. The patient was a 75-year-old man who had undergone endovascular stent-graft placement for a descending thoracic aortic aneurysm. The operation became necessary because the aneurysm continued to expand without evidence of endoleak. The postoperative course was uneventful, and without respiratory morbidity.

Tracheal Rupture

We previously published a bronchoscopic image of a tracheal tear involving the posterior tracheal wall during an elective surgical procedure.1 We now present a different image in which the entire tracheal was disrupted after emergency endotracheal intubation. A 77-year-old woman presented to an outside institution with atrial fibrillation and respiratory distress requiring urgent intubation. She subsequently developed increasing subcutaneous emphysema prompting x-ray evaluation, which demonstrated pneumomediastinum. Bronchoscopy performed at that time revealed a long membranous tear that extended to the carina. Bilateral chest tubes were placed and the patient was transported to our institution for definitive therapy. On arrival to the intensive-care unit (ICU), a computed tomography (CT) scan was reviewed and revealed extensive disruption of the trachea from above the sternal notch to the carina. The patient was urgently brought to the operating room where a repair was performed after placing the patient on cardiopulmonary bypass for appropriate oxygenation. The bronchoscopic image is presented below in Figure 1.FIGURE 1.: Note the full-thickness tear involving the posterior wall of the midtrachea.Repair was performed through a median sternotomy incision. Postoperatively, the patient was transferred to the thoracic ICU and doing well at the time of this writing. DISCUSSION Although uncommon, tracheal rupture after endotracheal intubation is well described and is said to occur characteristically in elderly females.2–4 Early and emergent repair is imperative to prevent life-threatening complications. Factors predisposing to tracheal laceration are summarized in Table 1.3,4Table 1: Factors Leading to Tracheal Tear or RuptureWomen are more susceptible to iatrogenic tracheobronchial rupture by virtue of their small body size, which puts them at increased risk of placing the tube too far downward in a short and weak membranous trachea.5 The most frequent cause of tracheal injury associated with intubation appears to be excessive cuff to tracheal wall pressure and inadequate tube size.6,7 It is postulated that excessive cuff pressure causes ischemic necrosis with subsequent rupture of the tracheal wall. In most instances, the posterior membranous wall ruptures longitudinally at the junction with the cartilage, and the length of rupture generally corresponds to the length of the cuff. Extensive tearing can be explained by further dissection under positive pressure ventilation.3 Signs of tracheal rupture, commonly subcutaneous emphysema and respiratory distress, appear immediately after intubation. Early radiographic findings include pneumomediastinum, subcutaneous emphysema, and pneumothorax. Pneumothorax occurs only if the tracheobronchial rupture communicates freely with the pleural space. Emergent flexible bronchoscopy is the best means of confirming the diagnosis and determining the exact location and extent of the lesion, which should be performed in the operating room. Aggressive management is essential to avoid life-threatening complications. Immediate complications include tension pneumothorax and anoxia because most of the tidal volume leaks through the tear. Subacute complications include potentially lethal mediastinitis and tracheal stricture.3 Tracheal intubation distal to the lesion or bronchial intubation with a double lumen tube and pleural drainage are of prime importance for control of respiratory distress. A few patients undergoing emergent repair in severe respiratory distress could require cardiopulmonary bypass. In patients with small tears when less than one third of the circumference of the trachea or bronchus is disrupted and in the absence of gross air leak or respiratory embarrassment, conservative management can be opted. However, any patient with a large tear or evidence of respiratory or circulatory compromise, primary surgical repair is the treatment of choice and must be performed at the earliest.3 Authors believe that even if care is applied during intubation, superficial lesions in the transbronchial tree are unavoidable, especially under emergency conditions. Large, iatrogenic disruptions can be avoided by using small endotracheal tubes and double-lumen tubes with carinal spurs should be generally avoided. Continuous monitoring of the cuff pressure is mandatory to overcome the problem of unnoticed cuff distension as a result of diffusion of nitrous oxide.8

Mitral valve repair in a 55-year-old man with left lung agenesis

We report on a 55-year-old man who was diagnosed with agenesis of the left lung in childhood. He was essentially asymptomatic until he was 53 years of age, when he became symptomatic with exertional dyspnea due to severe mitral regurgitation. We performed mitral valve repair using a median sternotomy incision approach.

The sheep as a model for coronary artery bypass surgery.

The sheep is considered to be a suitable model for cardiovascular surgery because of its ease of handling, size, and vascular anatomy which bears close resemblance to the human. Several difficulties, however, have limited the use of the sheep for such a purpose-mainly the high infection rate resulting from median sternotomy incision and its susceptibility to intractable ventricular fibrillation (VF) with the slightest manipulation of the heart, and even the risk of short periods of myocardial ischaemia. We have used the sheep model extensively to perform coronary artery bypass surgery and were successful in overcoming these difficulties. Fifty-seven adult female sheep were used to test a new anastomotic device for the creation of a sutureless connection between venous and arterial grafts and the coronary arteries. The study required full access to the heart and great vessels and mobilization of one of the internal mammary arteries. Changing to the left lateral thoracotomy (LLT) approach solved the initial fatal problems of postoperative infected median sternotomy incisions. Aggressive prophylactic treatment with anti-arrhythmic drugs, maintenance of normothermia and myocardial preconditioning rendered the heart much less vulnerable to manipulations and ischaemia. These measures have reduced the mortality rate from 45% to 0% (P <0.0001). With specific operative techniques and pharmaceutical interventions, the sheep can be effectively and safely used as a model for coronary artery surgery.

Use of a Continuous Local Anesthetic Infusion for Pain Management after Median Sternotomy

The use of large doses of opioid analgesics to treat pain after cardiac surgery can prolong the time to tracheal extubation and interfere with recovery of bowel and bladder function in the postoperative period. Therefore, the authors investigated the efficacy of a continuous infusion of bupivacaine 0.25% or 0.5%, at the median sternotomy site, for 48 h after cardiac surgery in reducing the opioid analgesic requirement and improving the recovery process. In this prospective, randomized, placebo-controlled, double-blind clinical trial, 36 consenting patients undergoing open-heart surgery with a standardized general anesthetic technique had two indwelling infusion catheters placed at the median sternotomy incision site at the end of surgery. The patients were randomly assigned to receive normal saline (control), bupivacaine 0.25% or bupivacaine 0.5% via an elastomeric infusion pump at a constant rate of 4 ml/h for 48 h. Patients evaluated their chest pain using an 11-point verbal rating scale, with 0 = no pain to 10 = worst pain imaginable. In addition, the postoperative opioid analgesic requirements and opioid-related adverse effects were recorded. Patient satisfaction with their pain management was assessed at specific intervals during the postoperative period using a 100-point verbal rating scale, with 1 = highly dissatisfied to 100 = highly satisfied. Finally, serum bupivacaine concentrations were measured 24 and 48 h after surgery. Compared with the control group, there was a statistically significant reduction in verbal rating scale pain scores and patient-controlled analgesia morphine use in the bupivacaine-0.5% group. Patient satisfaction with their pain management was also improved in the bupivacaine-0.5% (vs. control) group. However, there were no significant differences in patient-controlled analgesia morphine use between the bupivacaine-0.25% and control groups. Although the duration of the intensive care unit stay (30 vs. 34 h, respectively) was not significantly decreased, the time to ambulation (1 +/- 0.5 vs. 2 +/- 1 days, respectively) and the duration of hospital stay (4.2 vs. 5.7 days, respectively) were lower in the bupivacaine-0.5% group than in the control group. Mean +/- SD serum bupivacaine concentrations at 48 h in the bupivacaine-0.25% and bupivacaine-0.5% groups were 0.5 +/- 0.5 and 1.3 +/- 0.7 microg/ml, respectively. A continuous infusion of bupivacaine 0.5% at 4 ml/h is effective for decreasing pain and the need for opioid analgesic medication as well as for improving patient satisfaction with their pain management after cardiac surgery. Patients in the bupivacaine-0.5% group were able to ambulate earlier, leading to a reduced length of hospital stay.

Sternal wound debridement and muscle flap reconstruction: functional implications.

The mortality rate for poststernotomy infection, which occurs in as many as 5% of median sternotomy incisions after cardiovascular surgery, was 37.5% until sternal debridement with muscle or omental flap reconstruction became the standard treatment for this postoperative complication and lowered the mortality rate to just more than 5%. There are few reports in the literature of physical functional deficits and long-term outcome resulting from such reconstruction. The authors evaluated two groups of patients who had undergone coronary bypass surgery at least 6 months earlier. One group had no postoperative complications; the other group had developed marked sternal wound infections that required debridement and pectoralis major or rectus abdominis muscle reconstruction. Both groups underwent pectoralis and rectus muscle strength testing, evaluation of pain and ability to perform those activities of daily living that are dependent on pectoral and rectus muscle function, and completed self-assessment questionnaires. Differences between the two groups were significant (p<0.05) with regard to pain and patient satisfaction with appearance and general functional capacity. Pectoral muscle function and strength were significantly different in patients in whom that muscle was transposed. Rectus muscle strength was not affected by the transposition of a single rectus muscle. Physical morbidity and loss of strength seemed to be related directly to loss of sternal stability stemming from marked infection and debridement rather than from loss of the muscles used in reconstruction.

Mitral valve surgery and acute renal injury: port access versus median sternotomy

Background Many outcomes and complications of minimally invasive and conventional cardiac surgery await comparison. Patients undergoing mitral valve surgery commonly sustain renal injury. Using peak postoperative fractional change of serum creatinine as a marker of renal injury, we tested the hypothesis that mitral valve surgery with port access minithoracotomy (Port) and conventional surgery with a median sternotomy (MS) incision are associated with different degrees of acute renal injury. Methods We evaluated data from all isolated mitral valve operations by a single surgeon between 1990 and 2000 (MS = 90, Port = 227). We also performed a secondary analysis of mitral valve surgeries performed by both MS and Port approaches in a concurrent period from 1996 to 2002 (MS = 93, Port = 240). Univariable and multivariable tests were used to determine the association of surgical technique with peak postoperative creatinine (Cr maxPost) and peak postoperative fractional change in creatinine (%ΔCr); p less than 0.05 was considered significant. Results In our analysis that accounted for the date of surgery, we observed a highly significant independent association between surgical approach and %ΔCr, indicating a greater risk of acute renal injury in the MS group (F value 13.33; p = 0.0003). Similar findings were noted in the secondary (time-concurrent) analysis of %ΔCr (F value 12.65; p = 0.0176). Conclusions We present retrospective evidence of reduced acute renal injury associated with the port access technique in mitral valve surgery patients. Our findings suggest that a port access minithoracotomy approach to mitral valve surgery may be preferable to conventional methods for patients with high renal risk.

How animal-assisted therapy affects discharge teaching: A pilot study

How animal-assisted therapy affects discharge teaching: A pilot study

Effect of delayed sternal closure after cardiac surgery on respiratory function in ventilated infants.

Studies examining the effect of sternal closure on respiratory function have not been published, and currently there is little evidence to guide ventilation management immediately after closure. The aim of this study was to establish the impact of delayed sternal closure on expired tidal volume, respiratory system compliance, and CO2 elimination immediately after the procedure in infants who had undergone open heart surgery. Prospective study of respiratory function before and after delayed sternal closure. Cardiac intensive care unit, Great Ormond Street Hospital, London. Seventeen infants (median age, 2 wks) with open median sternotomy incisions after cardiac surgery. Data were collected between August 1998 and March 2000. Respiratory function was measured continuously for 30 mins before and after delayed sternal closure in paralyzed ventilated infants. Four babies were excluded from the study because they required either immediate increase in ventilation after delayed sternal closure (n = 3) or removal of pericardial blood collection (n = 1). In the remaining 13 infants, expired tidal volume and CO2 elimination decreased significantly (p < .005) by a mean of 17% and 29%, respectively, after sternal closure. In five of the remaining 13 patients, the magnitude of tracheal tube leak increased by > or = 10% after delayed sternal closure, thereby invalidating recorded changes in respiratory system compliance. Of the eight infants in whom there was a minimal change in leak, respiratory system compliance decreased significantly (p < .05) by a mean of 19%. This study supports the hypothesis that respiratory function may be compromised after delayed sternal closure and that ventilatory support should be increased to counteract the anticipated decrease in tidal volume. Extra vigilance should be applied in monitoring blood gases after delayed sternal closure to assess clinical responses to sternal closure or changes in ventilatory support. Accurate assessment of change in respiratory system compliance after any therapeutic intervention may be precluded by changes in tracheal tube leak during the procedure.

Multiple Penetrating Injuries to the Heart Diagnosed With Ultrasonography

Penetrating heart injury poses significant diagnostic and therapeutic challenges. Patients may initially appear in extremis or in stable condition. Surgeon-performed ultrasonography is effective in determining the presence or absence of tamponade. Definitive repair requires cardiorrhaphy, using a median sternotomy or thoracotomy incision, depending on the suspected injury site(s). Frequent postoperative complications can usually be managed without reoperation. Echocardiography, electrocardiography, and cardiac catheterization may be used postoperatively in reassessment. A patient with stab wounds to both ventricles of the heart is described.

Multiple Penetrating Injuries to the Heart Diagnosed With Ultrasonography

Penetrating heart injury poses significant diagnostic and therapeutic challenges. Patients may initially appear in extremis or in stable condition. Surgeon-performed ultrasonography is effective in determining the presence or absence of tamponade. Definitive repair requires cardiorrhaphy, using a median sternotomy or thoracotomy incision, depending on the suspected injury site(s). Frequent postoperative complications can usually be managed without reoperation. Echocardiography, electrocardiography, and cardiac catheterization may be used postoperatively in reassessment. A patient with stab wounds to both ventricles of the heart is described.

Contemporary management of children with atrial septal defects: a focus on transcatheter closure.

Atrial septal defects that result in right atrial and ventricular volume overload should be closed if diagnosed in children and adolescents. With closure of the atrial septal defect, the left-to-right shunt is eliminated e.g. the volume loading of the right heart, the excessive pulmonary blood flow and the total cardiac work load are reduced. The possibility of future arrhythmic events is lessened and paradoxical emboli across the septum eliminated. The first intracardiac surgical repair of a congenital lesion was a defect in the atrial septum nearly 50 years ago. Surgical closure remains a valuable, although viable technique. Recently percutaneous transcatheter techniques are now available. The conventional approach is via a median sternotomy incision but is associated with pain, risk of wound infection, postoperative immobilization and a permanent scar. It has been suggested that alternative approaches such as surgical repair using mini-sternotomy or lateral thoracotomy incisions yield similar results to the conventional surgical technique and are associated with fewer adverse effects. Transcatheter closure has developed over the last two decades and has evolved into a well tolerated, efficient and cost effective method with minimal discomfort for the patients. Complete closure rates are high and this approach has become a viable option for ASD management.

The management of pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries by definitive single stage repair in early infancy.

The management of infants and children with pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries (PA/VSD/MAPCA) has proven to be challenging. Therapeutic approaches have included staged unifocalization, shunting, coiling of collateral vessels, and heart/lung transplantation. Results have been variable and frustrating. Hoping to take advantage of growth potential in pulmonary segments supplied by MAPCA, a more radical approach was adopted in March of 1997. This consists of single stage complete unifocalization with closure of the ventricular septal defect and establishment of right ventricular to pulmonary arterial continuity with a cryopreserved pulmonary allograft (Rastelli type correction) through a midline sternal incision. During an 18-month period, eleven consecutive infants with PA/VSD/MAPCA underwent complete surgical correction. The ages ranged from 5 days to 5 months. Weights ranged from 2.2 to 5.6 kg. Through a standard median sternotomy incision, the pericardium and both pleural spaces were opened. Normothermic cardiopulmonary bypass was instituted. Section of all collaterals was accomplished without hypoxemia, and all collaterals were ligated at their origin from the aorta. They were then brought through posterior mediastinum to construct a pulmonary artery confluence. The ventricular septal defect was closed, and continuity was established between the right ventricle and the newly created pulmonary artery confluence with cryopreserved allografts. Ten of 11 patients survived operation, with postoperative courses that were uncomplicated. Length of stay ranged from 7-16 days, with a median length of stay of 11 days. One perioperative death occurred in a patient with preoperative co-morbidities of necrotizing enterocolitis, with no functioning gastrointestinal tract, intraventricular hemorrhage, and ventilator dependency since birth. At angiography, this patient has no demonstrable central pulmonary arteries and multiple diminutive aorta pulmonary collaterals. Autopsy revealed no demonstrable pulmonary arteries within the pulmonary parenchyma. All patients have been followed closely, and have grown normally. Two patients undergone repeat cardiac catheterization because of the echocardiographic demonstration of right ventricle pressures that had exceeded 50% of systemic. Both patients were treated with balloon angioplasty and one of these patients has had stenting of stenotic pulmonary arterial segments. No other patients have required additional hospitalization. Right ventricular pressures have remained less than fifty percent of systemic by echocardiographic assessment in all other patients. We feel that a single stage correction of pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries can be accomplished in early infancy with acceptable morbidity and mortality. The initiation of normothermic cardio-pulmonary bypass greatly facilitates dissection of collaterals and prevents hypoxemia. Interventional cardiology with balloon angioplasty and stenting of abnormal pulmonary arterial segments is both an important essential adjunct in the management of these patients. We remain optimistic that a single stage approach to this complex lesion coupled with cardiac catheterization, balloon angioplasty, and stenting, will provide long-term results superior to staged approaches.

Treatment of Coronary Heart Disease with Minimally Invasive Surgery

In 1998, most cardiac surgical practices used cardiopulmonary bypass (CPB) and cardioplegic arrest as techniques to perform coronary artery bypass grafting (CABG) (1). More than 25% of patients undergoing CABG have ≥1 complications (e.g., atrial fibrillation, bleeding, myocardial infarction, sternal infection, stroke, or renal failure). Although some of the morbidity of CABG is directly related to patient comorbidity factors, some of these complications are due to the current technique of CABG. The goal of minimally invasive CABG is to avoid the morbid complications of standard CPB-supported CABG. The 2 most common techniques of minimally invasive CABG are minimally invasive direct coronary artery bypass (MIDCAB) and offpump coronary artery bypass (OPCAB). For example, the median sternotomy incision is avoided in techniques that gain access to the heart via a left anterior thoracotomy (MIDCAB, Port-Access). CPB is avoided in techniques that perform coronary bypasses on a beating heart (OPCAB). In MIDCAB, both the sternotomy and CPB are avoided. One of the very first attempts at using the left internal thoracic artery (LITA) to revascularize the left anterior descending coronary artery (LAD) was done in a minimally invasive fashion, avoiding CPB. Professor Vasili I. Kolessov, in his pioneering 1967 work in LITA-to-LAD anastomosis, reported on an experimental study of 14 dogs with autopsy confirmation of patency at an intermediate-term (19 months) follow-up (2). In addition, he reported on 6 human patients. The surgery was conducted through a left anterior thoracotomy in the fifth intercostal space with LITA harvesting. Ischemic preconditioning for 6 to 8 minutes was afforded by coronary occlusion of the LAD using a snare. Anastomosis on a beating heart was performed with an interrupted silk suture technique, with or without a Vineberglike intramyocardial tunnel technique. Among the human patients, Kolessov reported 4 excellent results, the return of angina in 1 patient after 1 year, and 1 perioperative death. In this paper, I will examine the controversies related to the use of different techniques, present some pertinent data about them, perform Bayesian analysis comparing minimally invasive CABG and CABG-CPB, and review some comparative trials with the goal of clarifying the best uses of each technique.

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

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

Less-invasive heart surgery: the preservation of median approach.

Cardiac surgery has been traditionally performed via a median sternotomy incision where a large exposure of the mediastinum assured most of the cardiac procedures. Recently, the concepts of less-invasive surgery, well affirmed in many surgical specialties, led cardiac surgeons to develop limited accesses in coronary, valves and congenital operations. Between January and May 1997, 30 patients were operated on with a less-invasive approach. A short (6-9 cm) median incision followed by a subcomplete sternotomy permitted a limited opening of the chest without compromising the surgical exposure; a conventional central CPB was instituted and valve surgery and most of intracardiac procedures were performed without modification of the standard technique. No mortality was observed; morbidity was minimal. Cardiopulmonary bypass time and aortic cross-clamp time averaged 84+/-9 and 61+/-11 min, respectively. The majority of patients were extubated and discharged from the ICU early. Chest drainage lost on average 290+/-180 ml/m2. Despite our limited initial experience, this technique seems to provide several potential and practical advantages: there is less trauma and pain reported by patients; the small wound reduces the potential for wound infection and blood loss. Patients are extubated and discharged from the hospital earlier with lower overall costs.