Partial Sternotomy Research Articles

Reconstruction of aortic valve by autologous pericardium (Ozaki's procedure): Single center experience in Vietnam.

We aimed to report the experience of aortic valve reconstruction with autologous pericardium using Ozaki's procedure in Vietnam. The study included consecutive patients with isolated aortic valve disease who underwent Ozaki's procedure in our hospital between June 2017 and August 2019. Aortic valve leaflets were reconstructed with autologous pericardium using Ozaki's procedure. Sixty-one patients were included (mean age 55.8 years; 41 were male): 24 with aortic stenosis, 17 with aortic regurgitation, and 20 with both. Of the 61 patients, 16 had a bicuspid aortic valve, and 5 had infective endocarditis. The preoperative peak and mean gradient pressure gradients were 91.7 ± 16.1 mm Hg and 55.3 ± 10.3 mm Hg, respectively. Surgery was performed via a full or partial sternotomy. The procedure was successful in 59 cases. Two patients were converted to prosthetic valve replacement. The aortic crossclamp time was 110.9 ± 20.5 minutes. Intraoperative transesophageal echocardiography showed a mean pressure gradient of 8 ± 2 mm Hg and an aortic valve area of 3.04 ± 0.44 cm2. The mean follow-up period was 18.5 ± 5.7 months. One patient died in hospital due to cardiac tamponade. One patient underwent reoperation due to infective endocarditis 6 months after surgery. Another died at 8 months after surgery due to a mediastinal abscess. The surviving patients had no aortic regurgitation or mild aortic regurgitation at the last follow-up visits. Aortic valve reconstruction with autologous pericardium provided good outcomes in our study.

KẾT QUẢ DÀI HẠN PHẪU THUẬT CẦU NỐI ĐỘNG MẠCH CHỦ NGỰC - ĐỘNG MẠCH CẢNH - DƯỚI ĐÒN

Objectives: The complex stenosis of the branches of the aortic arch is rare, it was the challenge for vascular surgeon to manage. The purpose of thisstudy was review our experience with diagnosis and surgical treatment for complex stenosis of the branches of the aortic arch .Methods: Prospective. Eveluate the clinical characteristics of complex stenosis of the branches of the aortic arches. Diagnosis was based on Dupplex scanning, MSCT and angiography. Intrathoracic bypass was indicated for all cases. Results: From 10/1999 to 10/2011, twelve patients with complex stenosis of the branches of the aortic arch were treated in Choray hospital and Thong nhat hospital. 4 cases stenosis of the carotid and the subclavian artery; 4 cases have stenosis the branchiocephalic artery; and 4had stenosis all of the branches of the aortic arch. 10 cases admission because of chronic upper extremity ischemia. 12 cases had TIA. Takayashu’s disease affected in 6 cases, atherosclerosis was the cause of 6 patients. All patients were diagnosed by Duplex scan, MSCT and arteriography. 2 cases with 99 percent stenosis, the others were completely occluded.Upper partial sternotomy were performed in all cases.; Aorto carotido-subclavian bypass in 7 cases; Aorto bi-carotid bi-subclavian bypass were performed in 4 cases; Branchiocephalo carotid and subclavian bypass in 1 case, PTFE prothesis graft was used in 2 cases. Dacron prothesis was used in the rest .No procedure-related mortality was observed. No stroke. There are 1 wound infection, No restenosis after 12 years follow up.Conclusions: Upper partial sternotomy is a very good approach for ascending aorto carotidosubclavian bypass operation. Ascending aorto carotido subclavian bypass should be done for stenosis of multi-branches.

Partial upper sternotomy for concomitant left atrial ablation and aortic valve replacement.

Minimally invasive access via partial sternotomy has been established for aortic valve surgery in the past years. But concomitant procedures like atrial ablation and aortic valve replacement via partial upper sternotomy have not been investigated so far. We therefore present our operative technique and results in terms of safety and efficacy, including follow-up and quality of life. Between February 2007 and March 2014 a total of 67 patients undergoing isolated minimally invasive aortic valve replacement received concomitant left atrial ablation at our centre. Operative technique and short- and midterm results are described, including quality of life assessment using the SF-36 questionnaire. Operative techniqual success rate was 98.5%. We observed only one (1.5%) ablation-related conversion to full sternotomy. Operative times, reexploration and stroke rates as well as 30-day mortality are comparable to open procedures. Efficacy: The proportions of patients in sinus rhythm at discharge was 54.5% for paroxysmal AF patients and 27.7% overall. After a mean follow-up time of 38.0±22.6 months the cardiac related mortality rate was 4.5%, the rate of sinus rhythm was 72.7% for paroxysmal AF patients and 36.8% overall. Of survivors, overall mean quality of life was 7.3±2.1 as measured by SF-36. Concomitant left atrial ablation and aortic valve replacement can safely be performed via partial sternotomy and results are non-inferior to open surgery.

Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database

This study compares outcomes of conventional and less-invasive (LI) approaches for aortic valve replacement (AVR) using The Society of Thoracic Surgeons database. Between 2011 and 2017, we identified 122,474 patients undergoing isolated primary AVR. Patients were categorized into 3 groups: (1) full sternotomy (FS) (n= 98,549; 78%), (2) partial sternotomy (PS) (n= 17,306; 15%), and (3) right thoracotomy (RT) (n= 6619; 7%). The rate of LI-AVR increased from 17% in 2011 to 23% in 2016 (P < .001). Femoral cannulation was used in 1.5% of FS, 5.4% of PS, and 71% of RT patients (P < .001). Full sternotomy patients were older and had higher rates of preoperative renal failure, atrial fibrillation, and stroke, and had a higher NYHA function class, lower ejection fraction, and higher STS risk score. Total operative, cardiopulmonary bypass, and cross-clamp time were longest in RT-AVR patients and shortest in those who had FS-AVR. Overall, unadjusted operative mortality was 1.9% (1.05% among low-risk patients) and was not different among the 3 groups (1.97% FS, 1.77% PS, and 1.90% RT; P= .4). The rate of postoperative stroke was 1.2% and was not different among the 3 groups (1.2% FS, 1.3% PS, and 1.1% RT; P= .3). After risk adjustment, these differences remained nonsignificant. After risk adjustment, prolonged ventilation and atrial fibrillation were less common in PS-AVR patients. The adjusted risk for blood transfusion was lower in RT-AVR patients, as was the incidence of renal failure. Femoral cannulation was not associated with increased risk for stroke or mortality after LI-AVR. Less-invasive AVR is associated with an operative mortality and postoperative stroke rate similar to that of FS. Less-invasive AVRs should serve as a benchmark for comparison between transcatheter aortic valve replacement and surgical AVR in low-risk patients.

Resection of a desmoid-type fibromatosis with a CTNNB1 p.S45P mutation using a cervico-thoracic approach: A case report and literature review

Desmoid-type fibromatosis (DF) is a rare, locally infiltrative, and fibroblastic proliferative disease. DF usually arises from abdominal fascial tissue, but in rare cases, it can occur in extra-abdominal areas. A 73-year-old Japanese male complained of a painless, left anterior neck mass of 3-month duration. Computed tomography revealed the mass measured 9 × 7 × 6 cm and extended to the anterior mediastinum, with invasion of the left clavicle. En bloc resection of the tumor with the left sternoclavicular joint and the medial portion of the left clavicle was performed by cervico-thoracic approach with L-shaped partial sternotomy. Histopathologic examination showed fascicular growth of spindle-shaped cells separated by abundant collagen. Immunohistologic examination revealed nuclear staining of β-catenin and cytoplasmic staining of vimentin. Genetic analysis of 160 cancer-related genes by next-generation sequencing (NGS) demonstrated only a missense mutation in the CTNNB1 gene (c.133T>C, p.S45P). DF extending from the neck to the anterior mediastinum is rare. We report the complete resection of a large-sized DF with the clavicular invasion. A low-frequency CTNNB1 mutation of DF was identified. Genetic analysis with NGS was beneficial for the diagnosis.

Surgical treatment of recurrent goiter located in the posterior mediastinum

The article presents a rare variant of recurrent retrosternal goiter located in the posterior mediastinum. The localization and size of the goiter required the supplementation of traditional cervical access with a partial longitudinal sternotomy. It was shown relationship between the development of recurrent retrosternal goiter and nonradically performed primary operation.

One-Year Survival Rate after Thoracotomy for Left Ventricular Assist Device Implantation Compared with Sternotomy

Possible benefits of a left anterior thoracotomy approach for left ventricular assist device implantation have been reported recently, however, data of mid-term outcomes after this approach are scarce. This study compared the mid-term survival rate of a left anterior thoracotomy approach versus sternotomy. This is a single-center retrospective study of 264 patients who underwent centrifugal-flow left ventricular assist device (HeartWare, HVAD) implantation between 7/2011 and 12/2018 at our institution. After excluding 37 device exchange procedures and 17 patients who underwent any cardiac surgery prior to the implantation during the same hospitalization, 210 patients constituted the study cohort. The cohort was divided in two groups: a left anterior thoracotomy approach (LAT group; N = 42) and a full sternotomy approach (FS group; N = 168). The LAT group had higher rate of ischemic cardiomyopathy, cerebrovascular accident and previous cardiac surgery compared to the FS group. Although median operative time was longer in the LAT group (LAT; 255 mins vs FS 211 mins, P < 0.001), median cardiopulmonary bypass time was shorter (LAT; 52 mins vs FS; 68 mins, P = 0.040). The LAT group, compared to the FS group, had shorter ventilator support time (LAT; 22 hours vs FS; 36 hours, P = 0.001), less postoperative blood transfusion use (LAT; 57 % vs FS; 73 %, P = 0.042) and lower rate of moderate right heart failure (LAT; 33 % vs FS; 76 %, P < 0.001). A total survival rate at one-year after the implantation was 76.0 %. There was no statistical difference in one-year survival rate between the two groups (LAT; 73.2 % vs FS; 76.7 %, P = 0.632). Mid-term survival was similar between a left anterior thoracotomy with upper partial sternotomy and a full sternotomy. We will continue to follow these patients to compare the long-term outcomes between the two groups.

Minimally invasive approach for an adult patient with papillary fibroelastoma: reversed C-shaped partial sternotomy

Minimally invasive approach for an adult patient with papillary fibroelastoma: reversed C-shaped partial sternotomy

Tracheo-innominate artery fistula with continuous bleeding successfully treated through the suprasternal approach: a case report

BackgroundTracheo-innominate artery fistula (TIF) is a rare but fatal complication occurring after tracheotomy. Brachiocephalic trunk transection, one of the surgical treatments for TIF, is mostly associated with a full or partial median sternotomy. We describe a case of TIF with continuous bleeding, which was successfully treated with brachiocephalic trunk transection through a collar incision without the need for median sternotomy.Case presentationCase 1.An 18-year-old man was referred to our hospital with bleeding from a tracheal stoma, which had ceased prior to admission. TIF was suspected after examination. Innominate artery transection was performed through a collar incision. TIF was not revealed when we cut the innominate artery anterior wall open; therefore, we opted for preventive surgical intervention. The post-operative course was uneventful, and the patient was asymptomatic at the 3-year follow-up.Case 2.A 14-year-old male patient was admitted to our hospital with bleeding from a tracheal stoma, and TIF was suspected after examination. There was persistent bleeding when the cuff of the tracheotomy tube was deflated. Brachiocephalic trunk transection was performed through a collar incision using balloon occlusion. The post-operative course was uneventful, and rebleeding has not occurred 2 years later.ConclusionsBrachiocephalic trunk transection without any median sternotomy may offer the benefits of post-operative infection prevention. In patients with suspected continuous bleeding, using a balloon catheter may be a safe and effective method of treatment.

Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter

The anaesthetic management of retrosternal thyroid swellings has many associated problems. Positioning and induction may cause severe cardiorespiratory decompensation. Intubation may be difficult and may require all the gadgets for difficult intubation procedure. Rarely patients may require cardiopulmonary bypass to save life. Extubation may be difficult in patients with tracheomalacia. Post-operatively patients may require tracheostomy and ventilatory support. This is a case report outlining successful management of a patient with retrosternal goiter who underwent total thyroidectomy following partial sternotomy.

Anterior Mediastinal Kitlelere Cerrahi Yaklaşım

Aim: The aim of this study was to evaluate the clinical progress, type of surgical approach and early results of resection of anterior mediastinal masses. Patients and Methods: We retrospectively reviewed the reports of 25 patients who underwent surgery for an anterior mediastinal mass between 2014 and 2019. Patients’ age, gender, presenting symptoms, preoperative radiological investigations and surgical techniques were recorded. There were eight male and 17 female patients, and their age ranged from 18-89 with a mean of 44.4± 16.9 years. Results: The most frequent presenting symptoms were chest pain (90%) and cough (50%). The most common pathological diagnoses were thymic tumors (n=14, 56%) and lymphoma (n=5, 20%). Surgical approaches applied were median sternotomy in 16 patients, partial sternotomy in five patients and VATS (Video Assisted Thoracic Surgery) in four patients. There were no postoperative deaths or major complications, but eight patients had minor complications. Postoperative stay was 5±5.2 days. Conclusion:Surgery is a safe technique for diagnosis and treatment of anterior mediastinal masses.

Evaluation of Hybrid Surgical Access Approaches for Pulmonary Valve Implantation in an Acute Swine Model.

Percutaneous implantation of the pulmonary valve through peripheral vascular access can be limited due to poor venous access, low patient weight, hemodynamic or rhythmic instability, and size constraints related to the valve. In such cases, hybrid procedures may provide alternatives. Because the most commonly used median sternotomy is unsuitable for chronic trials in large animals, we evaluated several hybrid approaches for pulmonary valve replacement in a swine model. We tested the feasibility of hybrid pulmonary valve implantation in pigs by using inhouse-generated valves containing bare-metal or nitinol stents. Valves consisted of bovine jugular veins, bovine pericardial valves, or sprayed polyurethane valves. Access was achieved through median sternotomy, lower partial sternotomy, transverse sternotomy, or right lateral thoracotomy. The delivery device was introduced in a transventricular manner. Implantation took place under fluoroscopic and epicardial echocardiographic guidance. We achieved implantation of the stented valve in 12 (92.3%) pigs, of which 5 (41.7%) of the implanted valves were in an optimal position. Paravalvular leakage occurred in 2 trials (16.7%). Lower partial sternotomy provided the best trade-off between feasibility and minimized trauma for long-term animal trials. Here we describe our experience with hybrid pulmonary valve implantation in an acute large-animal (swine) model. We demonstrate the feasibility of the procedure in terms of surgical technique and the perioperative management and preparation of the field for a chronic trial.

Suitability of partial sternotomy for aortic valve and major aortic surgery

Suitability of partial sternotomy for aortic valve and major aortic surgery

Minimally invasive Ozaki technique

Implantation of a mechanical or biological graft remains the gold standard in treatment of patients with aortic valve pathology. However, the necessity of taking anticoagulants, the problem of graft durability, the risk for thromboembolic and haemorrhagic complications, prosthetic infective endocarditis impel surgeons to search for and develop new technologies. One of such new techniques is prosthetic repair of the aortic valve using autologous pericardium according to the S. Ozaki operation. This procedure makes it possible to form an aortic valve with excellent haemodynamic characteristics and low frequency of re-do operations in both the early and remote periods. Current trends are towards exponential growth of minimally invasive cardiosurgical interventions. Upper partial sternotomy is one of the most commonly used techniques in surgery of the aortic valve. The results of previous studies demonstrated that a minimally invasive approach apart from a good cosmetic effect has a series of advantages over full sternotomy by the in-hospital and remote outcomes. On the other hand, a minimally invasive access is associated with limited surgical exposure and tight operative field and is therefore technically more complicated than the operation via full sternotomy. In our retrospective study we compared the clinical outcomes of the minimally invasive Ozaki technique (Ozaki Mini Group, n=30) and full sternotomy (Ozaki Full Group, n=112). Because of differences between the groups by the clinical and demographic parameters in order to ensure maximum comparability we conducted computer-assisted propensity score matching, resulting in formation of 2 groups consisting of 30 patients each. The primary outcome measures of the study were 30-day all-cause mortality and postoperative major adverse cardiac events (myocardial infarction, stroke). As additional categorical outcomes we examined new-onset atrial fibrillation and renal failure, resternotomy, prolonged (>24 h) assisted artificial pulmonary ventilation, mediastinitis/sternal instability. Secondary outcome measures were as follows: the duration of the operation, duration of myocardial ischaemia and artificial circulation, blood loss, requirement for transfusion of donor blood components.

Indications and contra-indications for minimally invasive mitral valve surgery

A minimally invasive access through right mini-thoracotomy (MT) for mitral valve surgery (MIMVS) is indicated in all cases except those which cannot be safely addressed by this approach, i.e., in particular major annular calcification (MAC). Other conditions to be regarded as contraindications generally either impose an increased risk of complications compared to the standard approach (e.g., severe aorto-iliac atherosclerosis) or may simply jeopardize the results of MIMVS (any co-morbidity imposing an elevated surgical risk). Partial sternotomy (PS) represents an alternative less invasive approach for cases when MT is not feasible including severe MAC, concomitant aortic valve replacement (AVR) and selected indications for coronary artery bypass graft (CABG). Full sternotomy may be reserved for multiple bypass grafting, use of left internal mammary artery (LIMA), right internal mammary artery (RIMA) and reoperations when a MT approach is not appealing.

Mitral valve repair through partial upper sternotomy

Mitral valve repair through partial upper sternotomy

PC03.05 Debate on Standard Surgical Approaches - Open Thymectomy

PC03.05 Debate on Standard Surgical Approaches - Open Thymectomy

Sternotomy for management of myasthenia gravis: is the time to retire?

Surgical resection is the main treatment for myasthenia gravis (MG) associated with thymic hyperplasia or thymoma. The first thymectomy was performed in 1939 using full median sternotomy, but the morbidity and mortality related to sternotomy let surgeons to explore in selected cases less invasive approaches including transcervical or partial sternotomy (1-4).

Mediastinal Paratiroid Adenomlarında Parsiyel Sternotomi Uygulaması

Background: Solitary parathyroid adenomas are the most common cause of primary hyperparathyroidism. Generally neck exploration is adequate for parathyroid adenoma surgery, however some of them aren’t accessible using a cervical approach and sternotomy or thoracotomy can be required. In this study we present surgical application of eight cases with mediastinal parathyroid adenoma. Material and Methods: Between Jan 2006 - Mar 2018, eight patients who underwent partial sternotomy for mediastinal parathyroid adenoma in our clinic were included in the study. Patients' datas were retrospectively reviewed. Blood tests, radiographic and scintigraphic methods were performed and the results were reviewed. Localization of mediastinal parathyroid adenoma, performed treatment methods and prognosis were evaluated.Results: Seven of the cases were female (87.5%) and the mean age was found to be 49.7 years (range: 30-64 years). Bone pain what’s the most common symptom. All of the patients experienced hypercalcemia and hyperparathyroidia. PTH and Ca values returned to normal in postoperative period. No recurrent or consistent hyperparathyroidism was seen during follow-up period. No postsurgical morbidity or mortality developed. Conclusion: We claimed that partial sternotomy is a safe and adequate method for removing ectopic mediastinal parathyroid adenomas.

Early results of total arch replacement under partial sternotomy.

Partial sternotomy with limited skin incision has been utilized for cardiac surgery. We, therefore, started to apply the partial sternotomy for total arch replacement since 2013 in selected cases. The aim of this study reported the results of our early experiences. Between July 2013 and December 2015, we retrospectively reviewed 15 cases (median age 72, range 67-84, 15 male) who underwent total arch replacement thorough partial sternotomy. All procedures were performed under hypothermic circulatory arrest with selective cerebral perfusion. Median skin incision was 9cm (range 7-15cm, 5.3% of height) and partial sternotomy consisted of 14 upper and 1 lower partial sternotomy (L shape 8 and T shape 7 cases). Median operation time, cardiopulmonary bypass time, ischemic heart time, selective cerebral perfusion time and hypothermic circulatory arrest time were 485 [360-770], 223 [1174-270], 146 [100-163], 154 [116-189], and 69 [45-90] minutes, respectively. Median duration of mechanical ventilator dependent time was 12h [5-38]. Median length of ICU stay and hospital stay were 3 [1-7], and 18 [13-76] days, respectively. Thirty days and in-hospital mortality were 0% without any neurological complications. There are two aorta-related reoperation due to graft inducing hemolytic anemia and no aorta-related death during follow-up (median 954, range 702-1462 days). The early results of total arch replacement through partial sternotomy were satisfactory. The partial sternotomy could be a good option for total arch replacement in selected patients.