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PubMed1994

[The transverse submammary skin incision for median sternotomy].

Median sternotomy is the incision of choice to allow access to the anterior mediastinum, heart or both lungs. The vertical skin incision is cosmetically unsatisfactory for many female patients. The transverse submammary skin incision with dissection of a flap including the subcutaneous tissue and breasts allow exposure of the sternum for a median sternotomy. Seventy patients with the transverse submammary skin incision was compared with 56 patients with the vertical skin incision in the point of the cosmetic aspect and satisfaction of patients. The transverse submammary skin incision needed a longer wound size and took a longer time for cardiopulmonary bypass, but there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. The exposure of the mediastinum and the cosmetic result were excellent. The complications associated with this incision are insignificant if close attention is paid to details.

Adolescent↗
PubMed1994

Long-term results of flap reconstruction in median sternotomy wound infections.

Reconstruction of infected median sternotomy wounds using muscle and omental flaps has been shown to result in significantly reduced morbidity, mortality, and length of hospital stay. Despite these benefits, very little is known about the potential long-term sequelae of such procedures. The purpose of this study was therefore to evaluate the ultimate functional outcome in such patients. One-hundred and thirty-three consecutive patients underwent debridement and flap reconstruction of their infected median sternotomy wounds over an 8-year period. Eighty patients were available for follow-up and responded to a questionnaire. Forty-eight patients consented to a physical examination. The length of follow-up ranged from 15 to 108 months (average 48 months). Healed wounds were obtained in 99 percent of patients. Fifty-one percent of patients noted persistent pain or discomfort, particularly in the chest and shoulder. Forty-four percent noted areas of numbness/paresthesias, mainly on the chest. Thirty-four patients (42.5 percent) noted symptoms of sternal instability; of those consenting to an examination, 45 percent were confirmed to have instability. Twenty-six patients (32.5 percent) claimed postoperative weakness (shoulder/abdomen). Significant shoulder weakness was not demonstrated; however, abdominal weakness was substantial. Thirty-six percent of patients reported an inability to perform the same preoperative activities that were of importance to them (sports, housework, etc.). Of those patients eligible to return to work, 52 percent did not. Patients younger than age 60 had a somewhat higher chance of not returning to work. Scars were noted to be good to excellent in 75 percent, but contour abnormalities of the chest and abdomen were found in 85 percent.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Muscles↗
PubMed1994

Delayed sequelae of penetrating chest trauma: a plea for early sternotomy.

Penetrating wounds of the anterior chest wall are often associated with cardiac tamponade. Eighty to ninety percent of stab wounds to the heart result in acute tamponade, whereas delayed cardiac tamponade or hemothorax are rare, but hurtful for the patient. Of the cases reviewed, fifty percent of the patients who underwent sternotomy required repair of cardiac injuries. The presented case report adds further justification for early sternotomy in case of precordial penetrating chest injury in the danger zone.

Adult↗
PubMedDate not supplied

The Sternotomy Hemopump. A second generation intraarterial ventricular assist device.

The first generation Hemopump is a VAD based on a catheter mounted intraarterial axial flow blood pump that is placed through the femoral artery. Blood is withdrawn from the left ventricle through a transvalvular inflow cannula and pumped into the aorta. Clinical trials have demonstrated hemodynamic efficacy, improved survival, and low hemolysis in cardiogenic shock. The incidence of non-insertion of the device and fracture of the flexible drive cable limited its utility, however. In addition, some processes used in pilot production could not be adapted to volume manufacturing. A second generation device, the Sternotomy Hemopump, has been developed for insertion through the ascending aorta. Design changes include a shortened inflow cannula, higher flow hydraulics, and a more durable flexible drive cable. In addition, more efficient manufacturing processes were implemented. In a pulsatile mock loop the flow was 5.7 L/min at 100 mmHg. In vivo experiments of up to 2 weeks demonstrated a mean plasma free hemoglobin of 8.7 mg/dl, minimal valve injury, and an acceptable incidence of renal infarction. In vitro endurance demonstrated a 7 day reliability of 99.9% with a 95% confidence. A new clinical trial will evaluate the use of the Sternotomy Hemopump for nonoxygenator support during aorto-coronary artery bypass surgery.

Animals↗
PubMed1993

[Submammary incision for median sternotomy].

PURPOSE: To evaluate the indications, complications, cosmetic and functional results with submammary skin incision for a median sternotomy in females. METHODS: Two hundred and eighty female patients have undergone submammary skin incision for a median sternotomy between 1981 to 1991 ages ranged from 2 months to 42 years (m = 5 +/- 9 years). RESULTS: Adequate exposure of the heart was achieved in every case, there were no technical problems, no major complications and the cosmetic and functional results are excellent. CONCLUSION: Complications associated with this incision are insignificant and the cosmetic and functional results are excellent justified routinely this approach for young women.

Adolescent↗
PubMed1993

Ulnar neuropathy after median sternotomy.

Ulnar neuropathy is a known complication of median sternotomy surgery, and its precise cause is not clear. The authors hypothesize that a "double-crush" phenomenon caused by intraoperative compression of the brachial plexus occurs in a patient with preexisting, previously undiagnosed slowing of ulnar nerve conduction. Eighty-four arms in 42 patients scheduled for cardiac surgery were studied. Pre- and postoperative history and physical examinations were performed by separate blinded examiners; however, the nerve conduction studies were performed by a single examiner. Fifteen arms (18%) in 11 patients (26%) clinically demonstrated postoperative neuropathy. After surgery, all symptomatic patients had considerable slowing of their preoperative conduction studies. A direct correlation appears to exist between preoperative slowing of ulnar nerve conduction and postmedian sternotomy neuropathy. A careful preoperative evaluation including nerve conduction studies may detect the predisposed patient; the surgeon attempting postoperative cubital tunnel decompression is cautioned that the lesion may not be an isolated one.

Adult↗
PubMed1997

Early intervention and aggressive management of infected median sternotomy incision: a review of 2242 open-heart procedures.

Infected median sternotomy following open-heart surgery is a devastating complication with an incidence of 0.4 to 5 per cent and mortality as high as 80 per cent. Management varies from irrigation, debridement, closure with muscle, and skin flaps. We present our experience of early intervention and aggressive single-stage operative management. A retrospective chart review of all open-heart surgery patients was conducted from September 1984 through September 1994. Of the 2242 patients, 52 had infected median sternotomy incisions (2.3% incidence). The mean length of stay for reconstructive procedures was 18 days. The median interval to detection was 15 days, whereas the median interval to intervention was 4 days. There were five (6.8%) failed procedures and nine (12.3%) staged procedures. There were six deaths (11.5% incidence), one prior to receiving operative intervention. There was one false aneurysm. Single-stage reconstruction is safe, with results better than multistage procedures. It may be safely performed with a high success rate (93%). Early recognition and intervention significantly decreases length of stay.

Adult↗
PubMed1997

[Extended total aortic arch replacement involving the proximal descending aorta through a median sternotomy].

From January 1986 to September 1995, total aortic arch replacement (TAR) for aortic dissection was performed using selective cerebral perfusion in 151 patients. In 18 patients, the surgical procedures of extended aortic arch replacement (EAR) involving the proximal descending aorta through a median sternotomy were applied. To evaluate the outcome of EAR, the early and late results were compared with those of non-extended aortic arch replacements (NAR) through a median sternotomy (n = 66). The early mortality rates for EAR and NAR were 5.6% and 16.7%, respectively (NS); the lower rate for EAR may be due to the fact that EAR were performed more recently than NAR. The differences between EAR and NAR with respect to the amount of blood transfused intraoperatively and the respiratory index at 12 hours after surgery were not statistically significant. In addition, the extracorporeal bypass time in EAR was no longer than that in NAR. Thus, as compared with the NAR procedure, the EAR procedure did not have a negative effect on early outcome. Regarding late results, the actuarial survival rates after EAR and NAR, respectively were 87% and 72% at 1 year, 87% and 69% at 3 years (NS). The early thrombo-occlusion rates of the remaining false lumens after TAR in broad aortic dissections were 56% after EAR and 33% after NAR (p = 0.21). These results suggest that EAR may be a more useful procedure in some patients requiring TAR.

Aged↗
PubMed1997

Mini-sternotomy for aortic valve surgery.

In the recent years more and more efforts have been made widely to introduce new techniques in the minimally invasive cardiac surgery. At our Department and the Linköping University Hospital, Cardiothoracic Surgery Department, from August 1996 to January 1997, aortic valve surgery was performed in 23 adult patients (9 female, 14 male), age 28-86 years (mean age 62.5 years). Twenty-two patients had aortic valve replacement, among these, in 3 cases concomitant aortic annulus dilatation was made and in one case reduction-plasty of the dilated ascending aorta. In another one case resection of a sub-aortic membrane was performed. The operations and postoperative period were free of complications in all patients. Following an average 36 hours intensive care all patients were discharged after an average of 11.2 day hospital stay. The authors introduce the new surgical technique and present its advantages and disadvantages. Mini-sternotomy has less detrimental structural and functional effects on the thorax. Moreover, due to its minimal surgical trauma, this less invasive technique reduces patient morbidity, hospital stay and cost of care. Since mini-sternotomy is a safe and advantageous technique, the authors recommend applying this new technique in most of aortic valve operations.

Adult↗
PubMed2002

Treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye laser treatments.

OBJECTIVE: To compare the clinical response of keloidal and hypertrophic scars after treatment with intralesional corticosteroid alone or combined with 5-fluorouracil (5-FU), 5-FU alone, and the 585-nm flashlamp-pumped pulsed-dye laser (PDL). DESIGN: Prospective, paired-comparison, randomized controlled trial. SETTING: A private ambulatory laser facility. PATIENTS: Ten patients with previously untreated keloidal or hypertrophic median sternotomy scars at least 6 months after surgery that were considered problematic by the patients. INTERVENTIONS: Five segments were randomly treated with 4 different regimens: (1) laser radiation with a 585-nm PDL (5 J/cm(2)); (2) intralesional triamcinolone acetonide (TAC) (20 mg/mL); (3) intralesional 5-FU (50 mg/mL); and (4) intralesional TAC (1 mg/mL) mixed with 5-FU (45 mg/mL). One segment of each scar received no treatment and served as a control. MAIN OUTCOME MEASURES: Scar height, erythema, and pliability were evaluated before and every 8 weeks after treatment. Patients' subjective evaluations were tabulated. Histologic sections of segments were examined in 1 biopsy sample per segment at week 32. RESULTS: There was a statistically significant clinical improvement in all treated segments. No significant difference in treatment outcome vs method of treatment was noted. However, intralesional formulas resulted in faster resolution than the PDL: scar induration responded better to intralesional formulas, scar texture responded better to the PDL, and scar erythema responded the same as the control with all treatments. Adverse sequelae, including hypopigmentation, telangiectasia, and skin atrophy, were observed in 50% (5/10) of the segments that received corticosteroid intralesionally alone. No long-term adverse sequelae were demonstrated in the segments treated with other modalities. CONCLUSIONS: Clinical improvement of keloidal and hypertrophic scars after treatment with intralesional corticosteroid alone or combined with 5-FU, 5-FU alone, and PDL seemed comparable, with the exceptions of the incidence of adverse reactions, which were most common with intralesional corticosteroid. Intralesional 5-FU is comparable to the other therapies.

Adrenal Cortex Hormones↗
PubMed1982

Internal mammary arteriovenous fistula after sternotomy.

A patient who had undergone coronary artery bypass surgery was found to have a continuous murmur two weeks postoperatively. The diagnosis of internal mammary arteriovenous fistula was made by arteriography, which ruled out a more serious complication involving a saphenous vein to coronary artery anastomosis. The fistula was approached through the intercostal spaces above and below and ligated without difficulty. These are rare occurrences, usually asymptomatic, and are treated by ligation or ligation and excision. The etiology was thought to be closure of the median sternotomy incision with parasternal wires.

Arteriovenous Fistula↗
PubMed1985

Repair of subxiphoid incisional hernias with Marlex mesh after median sternotomy.

Median sternotomy is sometimes complicated by a bifid xiphoid process and an incisional (ventral) hernia in the subxiphoid region. Such hernias often recur after primary suture repair. We recently initiated the use of a polypropylene prosthetic mesh to primarily repair subxiphoid incisional hernias. This report details the results of using this material in 14 patients between January 1980 and December 1983. We also discuss the complex anatomy of the xiphoid region.

Adult↗
PubMed1989

Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection.

Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.

Cardiac Surgical Procedures↗
PubMed1985

Median sternotomy for metastatic lung lesions in 131 patients.

Aggressive management of malignant primary tumors and their metastatic manifestations is associated with improved survival outcomes. As investigators continue to focus attention on the ablation or control of pulmonary metastatic foci, surgery is gaining importance in the treatment of metastatic disease to the lungs and, in this context, is adjunctive to other therapeutic modalities. At Roswell Park Memorial Institute (RPMI), median sternotomy is preferred to unilateral or staged bilateral thoracotomies, since the former provides simultaneous access to both hemithoraces, whereas its lower morbidity facilitates the earlier resumption of systemic therapy. The RPMI experience, amassed from 131 patients and using this procedure, is presented and analyzed with respect to patient survival.

Adolescent↗
PubMed1986

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.

Adolescent↗
PubMed1996

Chylothorax following median sternotomy.

Reports of chylothorax (CT) following median sternotomy are rare, amounting so far to 16 cases in the English literature, of which 6 were cases of postcoronary artery bypass grafting (CABG). This report deals with an additional case of a 70-year-old woman who developed left pleural chylous effusion following CABG. It is suggested that the incidence of this type of pleural effusion is considerably greater than the few cases hitherto reported. Moreover, as CT may produce serious pulmonary and/or pleural functional impairment, it is proposed that a diagnostic tap be performed more often in cases of post CABG pleural effusion and that preventive drainage be instituted when CT is diagnosed.

Aged↗
PubMed2003

New technique for chest opening in mice: U-sternotomy.

In cardiac xenotransplantation, transfections with recombinant adeno-associated viruses could be a promising way of modulating the cardiomyocyte genome. Proteins like TRAIL, hDAF, Il-10, Il-4, and beta-galactosidase may be expressed on cardiomyocyte surfaces in order to prevent cellular rejection processes. However, after intracoronary perfusion with transfecting viruses, it takes up to 4 weeks before expression of the transgene can be detected. Mouse models have been established to create reliable transfection protocols. Currently, the major problem involves performing the intraaortic injection in mice without causing a lethal pneumothorax. Here we describe a new technique for chest opening to safely reach the mouse ascending aorta without opening the pleural space. This U-sternotomy reduces the risk of animal death and therefore the amount of quite expensive virus solutions needed.

Animals↗