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Experiments in goats showed that the application of bone wax to the divided sternum retarded healing. An autologous red cell compound was an efficient haemostatic and lacked the obstructive effect of wax. A human autologous red cell compound has been applied to the sterna of 15 patients following median sternotomy with good effect.
To date, the refixation of the bone halves after median sternotomy is accomplished with wire, steel bands or thick, not absorbable plastic threads. As the first, we used absorbable synthetic strings in 25 patients. During the absorbtion the development of a very strong bone scar was possible, because the absorbtion lasted very long. The refixation of the sternum in cases of aseptic instability was even possible. So we think to have found another range of application for absorbable synthetic material which recently has been used more and more in several parts of operative medicine, even in hard burdened connective tissue.
So far several methods have been established for refixing the sternum halves after longitudinal sternotomy like steel wire or steel strap according to Parham. The use of twisted absorbable PDS-strings is new. During experimental investigations in corpse sterna during tension load the different refixing methods were compared. As a result we found an increased tension stability of the sternum refixation as well as the reversibility of suture dehiscences, if occurred, after employment of the elastic PDS-string. Polydioxanon is a suggestive alternative compared with the usual not absorbable materials for refixation of the sternum.
A 66-year-old man, who had undergone DDD pacemaker implantation for complete A-V block two years ago, was admitted because of endocarditis with septicemia and renal failure. His blood culture revealed Staphylococcus aureus. We tried to remove the infected cardiac pacemaker lead. But we failed to remove the atrial lead because it was strongly adhered with the right atrial appendage. Antibiotic therapy was ineffective. In the last resort, we operated through median sternotomy three months after the initial infectious episode. In intraoperative inspection, we found it difficult to remove the lead by traction because of atrial residual lead sticking out of the right atrial appendage. We applied a purse string suture on the right appendage and obtained successful removal of infected lead without the cardiopulmonary bypass. His postoperative course has been uneventful. He is totally asymptomatic and doing well up to now. In case of such local infection, we conclude that all transvenous leads should be removed and recommend a simultaneous implantation of the epicardial pacemaker system.
A case of diffuse supravalvular aortic stenosis (SVAS) with Williams syndrome is reported. In this case of severe diffuse SVAS, we performed the diamond-patch aortoplasty in a child. However he has been suffering from residual SVAS. At 9-years old, the myocardial injury was noted by myocardial scintigraphy. Preoperative cardiac catheterization and angiography revealed the hypoplastic ascending aorta and arch with a pressure gradient of 89 mmHg at the distal site from the left subclavian artery. Through only a median stenotomy, an extended patch aortoplasty between the valsalva sinus and distal arch was performed and an extraanatomic bypass from the ascending aorta to the descending aorta was employed using a 10 mm tube graft. We realize this technique is available because this method can relieve the left ventriculus of the pressure load and operate via only median sternotomy.
Pseudoaneurysm of the internal mammary artery (IMA) following median sternotomy is extremely rare. To date, the reported cases are only in single figures. The majority of these pseudoaneurysms were suspected from the clinical presentation, echocardiography or computed tomography (CT) but were only confirmed on contrast angiography. This case report demonstrates the current ability to carry out detailed vascular imaging on a 16-slice CT scanner. This accurate delineation of the pseudoaneurysm allowed targeted therapeutic embolization to be performed without unnecessary angiographic imaging.
Median sternotomy (M-S) provides excellent exposure and allows dissection of the medial side of an anterior mediastinal tumor (AMT) with minimal risk. We report our experience of resecting AMT using M-S. Five children with AMT were treated using M-S between 1997 and 2004 at our institute. Ages at M-S ranged from 8 months (case 2) to 9 years (case 1) and AMT ranged in size from 5x6x7 cm3 (case 2) to large enough to occupy nearly the entire right thoracic cavity (cases 4 and 5). AMT were resected completely in all cases through M-S with the patient in the supine position. M-S alone was used in cases 1, 2, and 3, and cases 4 and 5 required additional incisions. There were dense adhesions between AMT and important mediastinal structures such as the anterior part of the pericardium (cases 1 and 2), left phrenic nerve (case 3), and pulmonary vessels (case 4, 5), but all were dissected safely under direct vision. There was no respiratory or cardiovascular compromise during M-S due to compression of the healthy lung and mediastinum. Histopathologic findings were mature teratoma in cases 1, 3, and 5, immature teratoma in case 2, and pleuropulmonary blastoma in case 4. Postoperative recovery was unremarkable. After mean follow-up of 3.4 years, cases 1, 2, 3, and 5 are currently well with no signs of recurrence, but case 4 died from disseminated intravascular coagulation during postoperative chemotherapy for massive local tumor recurrence 6 months after surgery. Based on our experience, M-S allows access to all aspects of AMT under direct vision, and provides excellent exposure, thus facilitating complete resection.
BACKGROUND: In minimally invasive coronary artery bypass surgery beating heart procedures and operations via limited incisions became more popular and are routinely performed in many centers. An additional approach to minimize general trauma is avoidance of general anesthesia endotracheal intubation. PATIENTS AND METHODS: Between March and June 2001, 14 spontaneously breathing patients underwent coronary artery bypass grafting on the beating heart without general anesthesia. Intra- and postoperative analgesia management was performed using continuous epidural infusion of local anesthetics at level Th2-Th3. Single (n = 8) as well as double (n = 5) and triple (n = 1) bypass grafting was performed with the off pump technique. Surgical access to the chest cavity was created via partial (n = 8) or complete sternotomy (n = 6). RESULTS: Twelve patients remained awake throughout the procedure; 2 patients required secondary intubation due to incomplete sensory block and pneumothorax. Operating time was 94 +/- 18 minutes. Intermediate care monitoring time amounted to 4.8 +/- 0.6 hours. No surgery-related complications or myocardial infarction occurred. Postoperative angiography reviewed good graft function in all patients. CONCLUSION: Our preliminary experience shows that complete surgical revascularization is safe and feasible without endotracheal intubation and general anesthesia. Thus, invasiveness in cardiac surgery is further reduced with less need for intensive care unit monitoring enabling faster mobilization and recovery.
Pulmonary margination of neutrophils may contribute to lung damage after extracorporeal circulation for cardiac surgery. We evaluated single-pass pulmonary neutrophil kinetics using the multiple indicator-dilution technique in control pigs (n = 10), after sternotomy alone (sterno, n = 10) or after 30 min of observation following a period of 90 min extracorporeal circulation (n = 7). Blood neutrophils increased in the control and sterno groups (p < 0.05) but remained unchanged in the extracorporeal circulation group. The transfer coefficient for neutrophil margination from the circulating to the lung-marginated pool (k(c-m)) and pulmonary neutrophil clearance (Cl(c-m)) were similar between the three groups. There was an inverse correlation between k(c-m) and the degree of lung tissue perfusion evaluated from the tracer-accessible extravascular lung water (r = -0.54, p < 0.01). There was no arterio-venous gradient of neutrophils in any of the groups, suggesting a dynamic equilibrium of the margination/demargination processes. We conclude that extracorporeal circulation does not significantly modify single pass pulmonary neutrophil kinetics 30 min after reperfusion. The rate of neutrophil margination to the tracer-accessible lung tissue suggests that lung tissue de-recruitment is associated with increased neutrophil margination.
We report the case of a 55-year-old man with a giant goiter descending to the mediastinum. Video-endoscopic surgery combined with a minimal sternotomy was performed to remove a thyroid tumor. In the course of our dissection of the subplatysmal space, an endoscopic approach was applied to avoid incisions of the neck. Three trocars were inserted from the anterior chest wall, and carbon dioxide (CO2) was insufflated at a pressure of 5 mmHg to create a working space. This technique improves the cosmesis of thyroidectomies and cervical operations.
BACKGROUND: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. METHODS: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. RESULTS: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 +/- 12) and 14 to 158 min (27 +/- 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. CONCLUSION: Our results suggest that MICS is a good option for surgical closure of ASD.
Active infection in the area of the tracheostomy during cardiac surgery presents a high risk. We successfully performed urgent aortic valve replacement for an endocarditis patient with active infection of methicillin resistance staphylococcus aureus in the tracheostoma. To avoid wound infection, a 2nd J-limited sternotomy was used during the operation. Despite malnutrition, the patient showed no wound infection after surgery and recovered smoothly.
A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The pre-operative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.
Major sternal infections developed in eleven of 1,550 patients undergoing median sternotomy for operations on the heart. Nine patients had myocardial revascularization, six with internal mammary artery as the conduit. Seven of these patients have been salvaged by aggressive local wound management and systemic support. These survivors have a good outlook for treatment of their basic cardiac disease.
We believe that when the indications for operation for spontaneous pneumothorax are met, the procedure of choice is bilateral resection of apical blebs and pleural abrasion through a median sternotomy. This approach allows easy access to both lungs and pleural spaces for a condition that is bilateral 100 per cent of the time. The operative morbidity is minimal and it essentially eliminates both ipsilateral and contralateral recurrence of pneumothorax with an operation that is of lesser rather than greater magnitude.
A case of an infant with median sternotomy wound infection and sternal necrosis treated by debridement and muscle flap transposition is reported. As in adults, the procedure can be done safely and successfully. Rapid healing and chest wall stability were obtained. A later cardiac procedure was performed without technical difficulties and without untoward effects on chest wall stability.
Two hundred twenty-one consecutive adult cardiac surgical patients were examined prospectively for nutritional protein state, acute phase protein response, and delayed hypersensitivity reaction in an attempt to identify patients at high risk for the development of sternal wound infection, which occurred in 6 patients (2.7%). There was no significant correlation between preoperative nutritional protein concentrations (retinol-binding protein, prealbumin, and transferrin) and acute phase protein levels (C-reactive protein, alpha 1-acid glycoprotein, and complements B and C3), nor a statistically significant relationship between nutritional state or acute phase protein response and the development of sternal infection. Preoperative complement C3 levels were elevated, however, in 80.0% of those in whom sternal infections developed compared with 30.6% of those with well-healed wounds. Similarly, postoperative concentrations of alpha 1-acid glycoprotein were elevated in 80.0% of those in whom sternal infections developed compared with 28.6% of those with well-healed wounds. There was no correlation between delayed hypersensitivity and the risk of sternal infection, nor between preoperative nutritional protein and acute phase protein values. Seventy-three percent of patients were anergic on postoperative day 2. Stepwise logistic regression showed that age, body weight, preoperative intensive care unit stay, repeat median sternotomy, internal mammary artery grafting, postoperative hemorrhage, and postoperative cardiac arrest correlated with the development of sternal infection, whereas transfusion requirement, reexploration for bleeding, and the operation performed did not. We conclude that routine delayed hypersensitivity testing is of no value in predicting high-risk cardiac surgical patients when the anergy battery is placed on the preoperative day. Although statistically insignificant, possibly due to the small number of patients in whom sternal infection developed in this study (type II error), a larger study might find preoperative complement C3 and post-operative alpha 1-acid glycoprotein levels to be predictive of patients at risk for the development of sternal wound infection. The final logistic model for the predicted risk 2%) of sternal wound infection is: PREDSWC = exp(EQ)/1 + exp(EQ) where EQ = (0.38 x age) + (0.24 x weight) + (5.42 x preop ICU) + (4.39 x redo) + (7.14 x IMA) + (4.49 x hemorrhage) + (8.81 x arrest) - 62.72, and where preop ICU, redo, hemorrhage, and arrest are defined as yes (1) or no (0), IMA-is defined as 0, 1, or 2, age is in years, and weight is in kilograms.
The case of a 73-year-old man in whom squamous cell carcinoma developed in a median sternotomy scar 12 months after coronary artery bypass grafting is presented. A brief review of the literature is included. The etiology of scar carcinoma is discussed and an outline of management given.