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PubMedDate not supplied

Prospective comparison between total sternotomy and ministernotomy for aortic valve replacement.

Ministernotomy (MS) is an alternative for total sternotomy (TS) in aortic valve replacement. We compared these two approaches for results and adverse effects in a prospective study. From January to December 2000, 100 patients who underwent aortic valve replacement were included in two groups of 50 according to the surgical approach that used MS or TS; one senior surgeon performed all cases in each group. Valvular pathologies were either stenosis or insufficiency. Mean age was 63 +/- 14 years in MS, 67 +/- 12 in TS (p = ns). NYHA class was 2.7 +/- 0.5 in MS, 2.8 +/- 0.6 in TS (p = ns). Left ventricular ejection fraction was 58 +/- 12% in MS, 57 +/- 12% in TS (p = ns). There was a significant difference between MS and TS in aortic cross-clamping (66 +/- 14 min vs 48 +/- 9 min) and cardiopulmonary bypass (88 +/- 18 min vs 69 +/- 10 min, p < 0.01), but not in intervention times (2.8 +/- 0.4 hours vs 2.7 +/- 0.4 hours). Mean intensive care stay was reduced in MS (1.7 +/- 1.6 days vs 2.6 +/- 6 days, p < 0.05). Intubation times (12 +/- 7 hours vs 14 +/- 9 hours), 24 hours bleeding (394 +/- 219 mL vs 465 +/- 318), reintervention for hemostasis (4% vs 2%), rhythmic complications (14% vs 14%), and mortality at 1 month (2% vs 2%) were comparable in MS and TS. In aortic valve surgery, ministernotomy is technically more demanding and needs more time. It is as safe and as effective as conventional sternotomy but its eventual benefits, excepting upon cosmesis, are still to be defined.

Aged↗
PubMed2004

The figure-L unilateral mini-sternotomy for anterior mediastinal tumor.

We performed a figure-L unilateral mini-sternotomy for anterior mediastinal tumor resection in ten patients. Pathological diagnosis among the ten included six thymomas, three mature teratomas including one with a seminoma component, and one thymic cyst. Mean tumor length was 7 x 5 x 4 cm. The required skin incision was 8 cm in mean length. The third intercostal space was transected in six cases, the fourth intercostal space in four cases. Bilateral internal thoracic arteries were preserved in all cases. All tumors were completely resected without complications during the procedure. Mean operating time was 106 minutes (range 85 to 120 minutes). Postoperative hospital stay ranged from three to seven days without any complications. All patients were alive at the end of a mean follow-up period of 39 months (range 3 to 60 months). The figure-L unilateral mini-sternotomy is considered an effective and useful minimally invasive approach for anterior mediastinal tumors.

Adult↗
PubMed2005

Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.

BACKGROUND: The aim of this study was to compare the early postoperative results of thymectomy operations after partial sternotomy and videothoracoscopy for myasthenia gravis. METHODS: A total of 51 thymectomy operations were reviewed. The surgical procedure was simple thymectomy with partial sternotomy in the first 19 patients (Group I) and videothoracoscopic thymectomy (Group II) in the remaining patients. Both groups were compared in terms of preoperative data (age, gender, classification, duration of disease, medications), operative data (operation time, the mean amount of drainage, the duration of chest tube drainage), and postoperative data (duration of hospital stay, complications and pain). RESULTS: Groups were statistically uniform in terms of preoperative and operative data. Statistically significant differences were noted for the duration of chest tube drainage (48.8 vs. 29.8 hours, p < 0.001), the amount of drainage (264.4 vs. 178.6 ml, p = 0.001), the length of hospital stay (5.6 vs. 2.3 days, p = 0.000), and the visual analogue scale score (4.8 vs. 3.1, p < 0.001). CONCLUSIONS: Thymectomy with videothoracoscopic surgery demonstrated a more comfortable and faster recovery period without deterioration in myasthenic status.

Adult↗
PubMed2006

Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure technique.

BACKGROUND: Sternal instability and mediastinitis are rare but serious complications following cardiac surgery with median sternotomy. METHODS: This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The conventional sternal closure technique, the parameters considered to be risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. In addition, a literature research with the key words "sternal closure technique" and "sternal dehiscence" was performed. RESULTS: Conventional closure of primary sternotomy is done using many different methods, most often with surgical steel sutures (87 %) passed trans/peristernally (64 %). An osteoporotic or fractured sternum (70 x), and obesity (31 x) were the most frequently cited risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method of Robicsek (48 x). CONCLUSION: There is no uniform osteosynthetic method for primary sternal closure and there is substantial variation in the perception of risk factors for sternal instability and possible surgical consequences among the surgical heart centers in Germany.

Biomechanical Phenomena↗
PubMed1998

Coronary artery bypass grafting by median sternotomy in patients with a tracheostoma.

The approach to the heart for open heart surgery in patients with a tracheostoma requires careful consideration. The presence of a tracheostoma interferes with the standard sternotomy and increases the risk of mediastinitis. We have successfully performed coronary artery bypass grafting in two patients with a tracheostoma using the limited median sternotomy and describe the surgical procedure used in these patients.

Coronary Artery Bypass↗
PubMed1991

Brachial plexus lesions following median sternotomy in cardiac surgery.

The incidence of neurological deficits of the upper extremity was studied in a prospective trial on 201 consecutive patients who underwent median sternotomy at cardiac surgery. In 13 patients (6.5%), a brachial plexus paresis was diagnosed postoperatively. We were unable to demonstrate any statistically significant correlation between brachial plexus paresis and the side of arm placement, the side of cannulation of the jugular vein, the duration of operation, the bypass time, sex, or type of operation. All patients who suffered from neurological deficit were aged 50 years and more, however without any statistically significant correlation. In our opinion, brachial plexus lesions following median sternotomy in cardiac surgery depend on the extent of sternal spread and the height of placement of the retractor in dependence of the rigidity of the rib cage. By reason of the iatrogenic cause of brachial plexus lesions, it appears to us that these complications should be included in those of which the patient needs to be informed preoperatively.

Brachial Plexus↗
PubMed2000

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children.

OBJECTIVE: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem. METHODS: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs). RESULTS: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations. CONCLUSIONS: Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.

Adolescent↗
PubMed2003

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis.

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.

Aged↗
PubMed1998

Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap.

Infected sternotomy wounds, particularly if accompanied by osteomyelitis, mediastinitis or pericarditis, are associated with significant morbidity, prolonged hospitalization and a mortality of up to 50%. Until the introduction of muscle flaps, the therapy of choice was debridement and open granulation or catheter irrigation. From 1994 to 1996, 9 patients with infected median sternotomy wounds were treated with a single-stage radical debridement and wound closure with a pedicled myocutaneous latissimus dorsi muscle flap (LDM). One patient received, in addition, a rectus abdominis muscle turnover flap. Healing was uneventful in all cases, with no respiratory complications or chest-wall instability. Shoulder strength was also unaffected. Functional and aesthetic outcome was good. The LDM provides a safe flap with little donor site morbidity. Compared to the most local muscle flaps, an intact IMA is not required. At the same time, length and cost of hospital stay are decreased.

Aged↗
PubMed1998

Nocardia farcinica sternotomy site infections in patients following open heart surgery.

Although Nocardia farcinica surgical site infection outbreaks have been reported (though rarely), no source for these has been identified. From May 1992 through June 1993, 5 patients contracted N. farcinica sternotomy site infections following open heart surgery at hospital A. A case-control study comparing case-patients (n=5) with open heart surgery patients without subsequent sternotomy site infections (n=50) identified as risk factors diabetes (4/5 vs. 11/50, P<.02) and exposure to a particular anesthesiologist (anesthesiologist A; 4/5 vs. 9/50, P<.01). Four case-patients' isolates and a hand isolate of anesthesiologist A had an identical ribotype pattern (strain 1); the remaining case-patient's isolate and multiple isolates from anesthesiologist A's hands and home had a different ribotype pattern (strain 2). An intensified hand-washing regimen, barriers (gloves, gowns), and cleaning of anesthesiologist A's house were associated with termination of the outbreak. This is the first reported nosocomial N. farcinica outbreak to document the source and person-to-person transmission epidemiologically and molecularly.

Aged↗
PubMed1985

Anaerobic mediastinitis complicating median sternotomy.

Two cases of mediastinitis and bacteremia caused by Bacteroides species following median sternotomy are described. In both patients, purulent sternal drainage and signs of systemic toxicity led to the diagnosis. Surgical reexploration and administration of appropriate antibiotics effected clinical cure. Although there is only a single previous case of anaerobic mediastinitis following median sternotomy incision reported, these two cases suggest that this unusual infection may not be so rare as previously thought.

Adult↗
PubMed2003

Use of a continuous local anesthetic infusion for pain management after median sternotomy.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Adult↗
PubMed1995

Long-term sequelae following median sternotomy wound infection and flap reconstruction.

Use of muscle and omental flaps has been shown to provide reliable reconstruction of infected median sternotomy wounds; however, few reports emphasize the long-term sequelae of the complication and its treatment. This study was performed to evaluate the long-term problems, including patient satisfaction and survival rate, in 88 patients with median sternotomy infections treated with muscle or omental flaps. Forty-two patients were available for long-term follow-up by telephone interview, with an average length of follow-up of 42 months. Forty-three percent complained of chronic chest wall pain or discomfort, and 45% complained of sternal instability. After pectoralis major muscle flap reconstruction in 32 patients, 25% complained of upper extremity weakness, and 56% complained of chest contour deformity. Delayed septic costochondritis or osteomyelitis occurred in 8%. Despite these unfavorable consequences, 72% and 83% of patients were satisfied with the cosmesis of the operation and the overall result, respectively. Furthermore, after hospital discharge, these patients seem to enjoy satisfactory longevity. By emphasizing the potential sequelae, further research interest may be stimulated in delineating their causes and in refining techniques of reconstruction.

Adult↗
PubMed1984

Bilateral pneumothoraces secondary to latrogenic buffalo chest. An unusual complication of median sternotomy and subclavian vein catheterization.

Pneumothorax following subclavian venipuncture is a well-known risk. Less well recognized is the potential for life-threatening bilateral pneumothoraces occurring at the time of subclavian vein catheterization in patients who have previously undergone median sternotomy. Inadvertent bilateral pleural entry at the time of sternotomy may result in a common pleural space which subsequently places the patient in special jeopardy when the complication of pneumothorax occurs. This report documents the successful management of this important sequence of complications associated with now widely applied therapeutic interventions.

Aged↗
PubMed1991

Long-term results of pectoralis major muscle transposition for infected sternotomy wounds.

During an 11.5-year period, 100 consecutive patients (79 male, 21 female) underwent repair of an infected sternotomy wound. Sixty-five patients had failed attempts at wound closure by other physicians. Median age was 61.5 years (range, 5 to 85 years). Reconstruction included muscle in 79 patients, omentum in 4, and both in 15. A total of 175 muscles were transposed, including 169 pectoralis major, 3 rectus abdominis, 2 external oblique, and 1 latissimus dorsi. Median number of operations was four (range, 1 to 11). Mechanical ventilation was required in 30 patients. Two perioperative deaths occurred, one related to sepsis. Median follow-up was 4.2 years (range, 1.3 to 13.5 years). Twenty-six patients had recurrent infection. Median time from our closure to recurrence was 5.5 months (range, 0.3 to 27.6 months). Cause of recurrence was inadequate removal of cartilage in 16 patients, bone in 6, and retained foreign body in 4. Eighteen patients had the wound reopened with further resection; 10 had another muscle or omentum transposition. There were 30 late deaths, only one related to recurrent infection. At the time of death or last follow-up, 92 patients had a healed chest wall. Transposition of the pectoralis major muscle remains an excellent method of management for infected sternotomy wounds. Failure is directly related to persistent infection of cartilage, bone, or retained foreign bodies.

Adolescent↗
PubMed1999

Planar scintigraphy and SPET with 99Tcm-HMPAO-labelled leukocytes in patients with median sternotomy: normal patterns.

The aim of this study was to determine the normal planar and SPET patterns of the thoracic distribution of 99Tcm-hexamethylpropylene amine oxime (99Tcm-HMPAO) in 20 patients who had undergone a previous median sternotomy and without infectious complications at follow-up. The study included anterior and oblique anterior planar views at 4 and 20 h. SPET of the chest was also carried out at 4 and 20 h. At 4 h, the planar views showed low background vascular activity in the lungs and cardiac region in addition to the sternal uptake, which showed two patterns: homogeneous in five patients and heterogeneous in 15. A long and narrow defect of uptake along the sternal midline was the most characteristic finding. At 4 h, in addition to the background vascular activity in the lungs and cardiac region, the greatest uptake on SPET was in the sternum anteriorly and the marrow spine posteriorly without any focal uptake, allowing visualization of the mediastinum free of focal activity. At 20 h, both the planar and SPET images showed a higher organ-to-background ratio. Knowledge of these post-surgical patterns will make it easier to interpret planar and SPET images when 99Tcm-HMPAO-labelled leukocytes are used in the diagnosis of mediastinitis and sternal infections in patients who had previously undergone median sternotomy. Planar views were better for the assessment of sternal uptake, but SPET views were better for the direct visualization of the mediastinum by eliminating overlapping sternal uptake.

Adult↗
PubMed1999

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.

Adult↗
PubMed1989

Risk factors for median sternotomy dehiscence in cardiac surgery.

We retrospectively reviewed several risk factors for median sternotomy dihiscence in our cardiac surgery patients for a recent 18-month period. We studied these factors by univariate and multivariate analysis with respect to sternal dehiscence. Univariate analysis showed several factors to be significant: female sex (P = .03), obesity (P = .002), diabetes (P = .01), and prolonged postoperative ventilation (P = .006). Mammary artery bypass versus saphenous vein bypass only approached significance (14% vs 3%, P = .11). Multivariate analysis showed obesity (P = .002), diabetes (P = .041), and prolonged postoperative ventilation (P = .005) to be important. We conclude that obese diabetic women are at extremely high risk for sternotomy dehiscence, and mammary artery bypass in this high-risk population may be a relative contraindication.

Adult↗