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PubMedDate not supplied

Spinal deformity after combined thoracotomy and sternotomy for congenital heart disease.

UNLABELLED: Patients with congenital heart disease are at an increased risk to develop scoliosis. The purpose of this study was to determine the incidence of spinal deformity in patients after thoracotomy and sternotomy for congenital heart disease. METHODS: Sixty-eight patients underwent thoracotomy followed by a sternotomy and met inclusion criteria. The medical records were reviewed to gather demographic data and medical and surgical history. Serial radiographs were reviewed. RESULTS: Scoliosis developed in 26% of the patients (10 boys, 8 girls). The mean Cobb angle was 40 degrees (range, 15-78 degrees). The mean age at diagnosis of scoliosis was 10.7 years (range, 2.9-17 years). The mean follow-up was 14.9 years (range, 5-20 years). Twelve percent (8 patients) required posterior spinal fusion. A kyphotic deformity developed in 21% (14 patients). In patients with scoliosis, the mean kyphosis was 38 degrees (range, 2-88 degrees). Patients with a cyanotic cardiac condition had a 4-fold incidence of scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, sex, heart size, or side of the aortic arch. CONCLUSIONS: The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or hyperkyphosis, were found in 38% of the patients. Curves develop at a younger age, which increases the risk of progression. The sagittal alignment in scoliosis patients tends toward hyperkyphosis. The thoracic spine receives a "double hit" when both procedures are combined.

Child↗
PubMed2003

Two-stage reconstruction of infected deep median sternotomy wound with an intercostal pedicled oblique rectus abdominis musculocutaneous flap after coronary artery bypass grafting.

Median sternotomy wounds infected after coronary artery bypass grafting with bilateral internal mammary arteries are generally poor in condition, cannot be debrided adequately, and are limited in flap selection for reconstruction. The authors treated 2 patients with two-stage reconstruction using a modified superior-based rectus abdominis musculocutaneous flap. First, simple debridement was performed with the goal of preserving the internal mammary artery grafts. Then, delayed reconstruction with the oblique rectus abdominis musculocutaneous flap supplied by the superior epigastric and seventh intercostal vessels was performed. Despite ligature of the bilateral internal mammary arteries at their full length, the large oblique skin paddle designed along the angiosome as far as the midaxillary line survived almost completely in both patients, resulting in cessation of pus discharge. The circulation to the superior epigastric and intercostal vessels might be reinforced because of the delay phenomenon. Two-stage reconstruction with a superior pedicled oblique rectus abdominis musculocutaneous flap presents a successful resolution of infected median sternotomy wounds after coronary artery bypass grafting with sacrifice of bilateral internal mammary arteries.

Aged↗
PubMed1986

Influence of ketanserin pretreatment on the haemodynamic responses to sternotomy.

The effect of intravenous ketanserin on the pressor response to sternotomy was studied in 36 patients undergoing coronary artery surgery. Two doses of the drug (10 mg and 20 mg) were compared with a placebo injection of saline. After induction of anaesthesia, haemodynamic variables were measured until the institution of cardiopulmonary bypass. Plasma and platelet 5-hydroxyindoles and 5-hydroxytryptamine were measured in a subset of 13 patients. Ketanserin induced a dose-dependent amelioration of the pressor response to sternotomy. Plasma 5-hydroxyindoles and platelet 5-hydroxytryptamine levels did not correlate with clinical response. The increased effectiveness of the higher dose of ketanserin may be due to an effect other than serotonin antagonism.

Drug Evaluation↗
PubMed1993

Topical nitroglycerin prevents the pressor response to tracheal intubation and sternotomy in patients undergoing coronary artery bypass graft surgery.

Thirty adult patients who underwent coronary artery bypass graft surgery were allocated randomly to one of two equal groups to receive either 2% nitroglycerin, or a placebo ointment, applied topically over an area of 5 cm by 10 cm, in a double-blind manner, 1 h before induction of anaesthesia. Premedication consisted of oral diazepam 5-10 mg, intramuscular morphine 0.2 mg.kg-1 and promethazine 0.4 mg.kg-1. Anaesthesia was induced with morphine 0.15-0.2 mg.kg-1 and thiopentone 3-5 mg.kg-1. Laryngoscopy and tracheal intubation were facilitated by suxamethonium 1.5 mg.kg-1, and pancuronium 0.1 mg.kg-1 was used for subsequent muscle relaxation. Anaesthesia was maintained with 0.5% halothane and 40% oxygen in nitrous oxide. A significant increase in blood pressure occurred during and after laryngoscopy and tracheal intubation, and following midline sternotomy in the control group. These changes were absent in patients pretreated with topical nitroglycerin. The nitroglycerin group also maintained a lower rate-pressure product than the control group. We conclude that topical nitroglycerin is a simple and useful pretreatment to prevent the pressor response to tracheal intubation and midline sternotomy in patients undergoing coronary artery bypass graft surgery.

Adult↗
PubMed1985

Left ventricular function during anaesthesia induction and sternotomy in patients with ischaemic heart disease. A comparison of six anaesthetic techniques.

A comparison between five anaesthetic procedures, fentanyl (FE), morphine (MO), halothane (HAL), fentanyl/droperidol (NLA) and thiopenthone (two dose levels: PE 3 and PE 6), all supplemented with nitrous oxide, was performed with respect to the left ventricular function (LVF) during anaesthesia induction and sternotomy in 47 patients with good preoperative LVF and maintained beta-blockers. Peroperative LVF was characterized by left ventricular stroke volume (stroke index) and external pressure volume stroke work (left ventricular stroke work index) in relation to filling pressure (pulmonary capillary wedge pressure) and outflow resistance (systemic vascular resistance). The individual patient patterns in each group indicated normal LVF in the awake state. Anaesthesia induction was followed by a moderate depression of LVF in the HAL, MO, PE 3 and PE 6 groups at full dose of anaesthetic agent. After addition of nitrous oxide, there was also a decrease of preload in all groups, masking any additional depressions of LVF. The response to external stimuli, endotracheal intubation and sternotomy was that of mildly depressed LVF in the majority of the patients. The haemodynamic reactions in the FE and NLA groups were more varied. In all groups some patients (approximately 30%) showed signs of left ventricular failing in response to external stimuli. With the exception of the more variable haemodynamic reactions in the FE and NLA groups, the differences between the anaesthesia groups with respect to LVF depended mainly on extracardiac factors.

Anesthesia↗
PubMedDate not supplied

Ineffectiveness of local wound anesthesia to reduce postoperative pain after median sternotomy.

Postoperative pain control still represents a major challenge in every surgical field. Bupivacaine wound infiltration is frequently used to reduce the pain related to the surgical incision itself. In this randomized study, we investigated the efficacy of bupivacaine local anesthesia after median sternotomy to reduce postoperative pain. Forty-seven patients undergoing major cardiac surgery procedures were allocated randomly to group A (bupivacaine wound infiltration 0.5%; 10 mL, followed by continuous infusion: 10 mg/24 H) or to group C (controls). Extubation time, postoperative arterial blood gases, postoperative pain (assessed by means of a visual analog scale), and morphine consumption were the endpoints of the study. Patients of group C were extubated earlier; blood gases and VAS values were similar in both group. Bupivacaine local analgesia did not improve postoperative pain control after median sternotomy.

Aged↗
PubMedDate not supplied

Modified sternotomy to minimize infection risk in patients with prior laryngectomy and permanent tracheostomy.

Patients with prior laryngectomy and permanent tracheostomy undergoing complete sternotomy historically are at increased risk for wound infection, osteomyelitis, mediastinitis, bleeding, tracheal injury, and poor wound healing. We describe three patients who underwent cardiac surgery via low midline incision with transverse flap, providing the exposure of complete sternotomy and decreased infectious risk. Patient selection, technique, and management principles are discussed.

Aged↗
PubMed1996

Review of the technique and complications of median sternotomy in the dog and cat.

The surgical and medical records of 67 dogs and nine cats which underwent median sternotomy over a five-year period were reviewed. The indication for median sternotomy and the short and longer term complications were recorded. Twenty-six of the dogs died or were euthanased within 48 hours of the surgery as a consequence of the pre-existing disease or complications of the intrathoracic surgical procedure. A further four dogs were enthanased between 48 hours and 14 days following confirmation of neoplastic processes. Thirty-seven dogs were alive at 14 days: of these, seven dogs (19 per cent) experienced short-term wound complications, including haemorrhage, wound infection, thoracic limb neurological deficits and excessive postoperative discomfort. Of the 37 dogs alive for longer term follow-up, eight dogs (22 per cent) experienced wound complications, including haemorrhage, sternal fracture, sternal osteomyelitis and delayed wound healing. No complications were noted in the cats.

Animals↗
PubMed1975

Fracture of the first rib as a complication of midline sternotomy.

Fracture of the first rib occurred in six patients after cardiac surgery through a midline sternotomy. Two of the fractures could not be seen on the chest films and were demonstrated only on oblique radiographs of the cervical spine. Symptoms simulating myocardial infarction and/or pulmonary embolism were present in three of the six cases. In a review of 50 randomly selected cases of midline sternotomy, first-rib fractures were found in 3(6%).

Adult↗
PubMed1976

The midsternal stripe: a sign of dehiscence following median sternotomy.

Sternal dehiscence is a recognized complication of median sternotomy in 2.5-4.8% of patients. The authors describe the prognostic significance of a lucent midsternal stripe which was seen in 12 patients over a two-year period. Sternal dehiscence requiring surgical revision developed in 4, and radiological suspicion preceded clinical evidence of dehiscence in 3 of them. A review of 100 consecutive median sternotomies revealed that sternal dehiscence did not develop in any patient who did not have a midsternal stripe. It is suggested that this may be a useful tool in identifying those patients who are at high risk of the development of sternal dehiscence.

Adult↗
PubMed1993

MR imaging in the evaluation of the chest after uncomplicated median sternotomy.

Although complications of median sternotomy are infrequent, they are associated with high morbidity and mortality. Current imaging modalities have proved to be of limited value in the evaluation of these abnormalities. The search for more efficacious means of assessment is continual. The appearance of the thorax was evaluated in 10 patients who were undergoing median sternotomy for coronary artery bypass graft surgery. Three serial magnetic resonance (MR) imaging examinations were performed on each patient. These examinations included a baseline preoperative study and two postoperative studies. Each patient included in the study had an uncomplicated postoperative clinical course. Usual postoperative findings included pleural effusions, pulmonary parenchymal abnormalities, mediastinal edema, and pericardial effusions. On the basis of this limited study, the authors believe that MR imaging is a feasible means of evaluating the chest after surgery. An appreciation of the normal postoperative appearance is essential before complications can be reliably identified and characterized.

Artifacts↗
PubMed1996

Mediastinitis following median sternotomy: CT findings.

PURPOSE: To evaluate the usefulness of computed tomography (CT) in the diagnosis of mediastinitis following median sternotomy. MATERIALS AND METHODS: Fifty patients aged 6 weeks to 80 years (31 male, 19 female) who underwent CT for clinically suspected mediastinitis following median sternotomy were retrospectively identified. CT scans were evaluated for primary findings (localized mediastinal fluid, pneumomediastinum, or both) versus secondary or other findings (mediastinal edema, adenopathy, pleural effusion, or a sternal or lung abnormality). Patients were divided into three groups on the basis of the CT findings and final clinical diagnosis: those with primary CT signs and a final diagnosis of mediastinitis, those with primary CT signs of mediastinitis and a different final diagnosis, and those with neither primary CT findings nor a final diagnosis of mediastinitis. RESULTS: All patients with clinical mediastinitis had primary CT findings. These patients under went CT an average of 24 days after surgery. Patients with primary CT findings and a final clinical diagnosis of something other than mediastinitis underwent CT an average of 9 days following following surgery. Through postoperative day 14, CT had a sensitivity of 100% for clinical mediastinitis but a specificity of 33%; after postoperative day 14, the sensitivity was 100% and the specificity was 100%. CONCLUSION: Primary CT findings are not specific for mediastinitis through postoperative day 14; after day 14, they are highly indicative of mediastinitis.

Adolescent↗
PubMed1985

Respiratory and haemodynamic effects of lateral thoracotomy or sternotomy in mechanically ventilated rats.

We compared left lateral thoracotomy and sternotomy in rats which were mechanically ventilated for at least 1 h in order to perfect the technique and the surveillance of thoracic opening. Lateral thoracotomy proved to be superior to sternotomy as it was associated with a lower mortality within the first 24 h (20% compared with 50%; p less than 0.05). Lateral thoracotomy causes a smaller reduction in mean blood pressure (104 +/- 11 vs. 71 +/- 7 mm Hg; mean +/- SD; p less than 0.05). Furthermore, following lateral thoracotomy, the rats had a higher postoperative PaO2 (77 +/- 16 vs. 72 +/- 7 Torr) and a lower PaCO2 (29.5 +/- 1.5 vs. 35 +/- 4.3 Torr), although these differences were not statistically significant.

Animals↗
PubMed1993

Combined median sternotomy and video-assisted thoracoscopic resection of pulmonary metastases.

Median sternotomy has been a common approach for resection of bilateral pulmonary metastases. It provides good exposure and quick accessibility to most lesions in the lung. The retrocardiac left lower lobe may at times be a problematic area for resection of metastases. We have used a simultaneous median sternotomy and left video-assisted thoracoscopic approach to remove three such lesions in two patients, with satisfactory results.

Humans↗
PubMed1996

Factors predisposing to median sternotomy complications. Deep vs superficial infection.

STUDY OBJECTIVES: Median sternotomy infections are a serious complication of cardiac surgery. The purpose of this study was to determine the patient characteristics and operative variables that predict incidence of sternal infection, and possibly its severity. DESIGN: Univariate and multivariate retrospective analysis comparing patient, operative, and post-operative data in patients with and without sternal infections. SETTING: Cardiac surgery program of a 580-bed private hospital in Toledo, Ohio. PATIENTS: We studied 2,317 consecutive (June 1991 to December 1994) patients undergoing cardiac surgery. RESULTS: Forty-one sternal infections were documented. Of these, 21 (0.91%) were deep infections with mediastinal involvement and 20 (0.86%) were superficial. Two patients with deep infections died (2/41, 5%). Ten variables were associated with infection by univariate analysis (p < 0.05), and of these, five were independent predictors by multivariate logistic regression. These predictors were obesity (p < 0.001), insulin-dependent diabetes (p < 0.001), use of internal mammary artery grafts (p = 0.02), surgical reexploration of the mediastinum (p = 0.003), and postoperative transfusions (p = 0.01). Predictors of deep and superficial sternal infection did not differ. Length of hospitalization was substantially longer for patients with deep (32 +/- 21 days) vs superficial infection (13 +/- 10 days). CONCLUSIONS: The present study confirms previous findings that obesity, insulin-dependent diabetes, and internal mammary artery grafting (especially bilaterally) increase the risk of sternal infection. In addition, chest surgical reexploration and blood transfusions were postoperative factors that predisposed patients with median sternotomy to infection. Unlike their associated morbidity and mortality, predictors of deep and superficial sternal infections are similar.

Analysis of Variance↗
PubMed1998

Upper T mini-sternotomy for aortic valve operations.

OBJECTIVES: New minimally invasive approaches for cardiac surgical procedures are constantly being developed in the hope of decreasing patient morbidity and enhancing the postoperative recovery. This report reviews the use of an upper T mini-sternotomy approach to aortic valve surgery. PATIENTS: Nine consecutive nonselected patients (5 men, 4 women, mean age, 66 years) underwent isolated aortic valve replacement with the use of this approach. Two patients had isolated aortic valve stenosis, three had isolated aortic valve incompetence, and four patients had mixed aortic valve disease. RESULTS: In all cases, an excellent view of the aortic valve was obtained, aortic valve replacement with a bileaflet mechanical prostheses was performed, and no intraoperative difficulties were encountered. Mean aortic cross-clamp time was 83 min and mean cardiopulmonary bypass perfusion time was 97 min. All patients were extubated in the operating room at the end of the surgical procedure, and there were no postoperative complications. All patients were discharged home on postoperative day 3, and there were no late complications. CONCLUSION: Through an upper T mini-sternotomy, aortic valve surgery can be performed in the conventional manner using standard surgical instruments with no alteration in cardiopulmonary bypass and myocardial protection routines. With this method, postoperative pain is reduced and patient recovery is expeditious.

Aged↗
PubMed2004

Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds: a randomized trial.

STUDY OBJECTIVE: To compare three dressing types in terms of their ability to protect against infection and promote healing, patient comfort, and cost-effectiveness. DESIGN: Prospective, randomized controlled trial. SETTING: Major metropolitan, academically affiliated, tertiary referral center. PATIENTS: Seven hundred thirty-seven patients were randomized to receive a dry absorbent dressing (n = 243) [Primapore; Smith & Nephew; Sydney, NSW, Australia], a hydrocolloid dressing (n = 267) [Duoderm Thin ConvaTec; Mulgrave, VIC, Australia], or a hydroactive dressing (n = 227) [Opsite; Smith & Nephew] in the operating theater on skin closure. RESULTS: There was no difference in the rate of wound infection or wound healing between treatment groups. The Primapore dressing was the most comfortable and cost-effective dressing option for the sternotomy wound. Duoderm Thin dressings were associated with increased wound exudate (p < 0.001), poor dressing integrity (p < 0.001), more frequent dressing changes (p < 0.001), more discomfort with removal (p < 0.05), and increased cost (p < 0.001). CONCLUSIONS: In the context of no additional benefit for the prevention of wound infection or the rate of wound healing for any of the three dressing products examined, dry absorbent dressings are the most comfortable and cost-effective products for sternotomy wounds following cardiac surgery.

Aged↗
PubMed1976

Cardiac tamponade complicating closure of a median sternotomy.

A case of intraoperative cardiac tamponade manifested during closure of a median sternotomy is presented. We postulate that cardiac tamponade was caused by acute dilatation of the cardiac chambers as a result of intraoartic balloon pumping in a patient with aortic and mitral regurgitation. It has been shown experimentally that acute rises in ventricular end-diastolic pressure result in increased intrapericardial pressure and that if a certain point on the pericardial pressure-volume curve is reached, cardiac tamponade will occur. Sternotomy closure was accomplished easily as soon as the need for intra-aortic balloon pumping diminished.

Aortic Valve Insufficiency↗