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PubMed2001

Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) can be performed in several ways using a minimally invasive approach (MIDCAB). Using the left anterior small thoracotomy (LAST) approach, only the LAD can be grafted. To expand the indications for MIDCAB from single-vessel disease to double-vessel disease, we have used a partial sternotomy without a transverse cut, namely, the lower-end sternal splitting (LESS) approach. Through this approach, the LAD and RCA can be revascularized by means of a single small incision without the risk of damaging the tissue around the intercostal space during harvesting of ITA when the sternum is transversely divided. The purpose of this study was to demonstrate the feasibility and safety of this technique. METHODS: Between November 1999 and November 2000, a total of 22 patients underwent MIDCAB through a lower midline skin incision from the fourth intercostal space to the xiphoid process with longitudinal division of the lower half sternum up to the 3rd rib, without either a T- or reversed L-shaped division of the sternum. Of the patients, 14 had LAD disease only, 5 had both LAD and RCA disease, 2 had RCA disease only, and 1 had left main trunk disease. Two of the operations were of redo coronary artery bypass grafting. The mean age was 69.5 +/- 6.1 years (range 58 to 77 years). RESULTS: The mean length of the skin incision was 8.5 +/- 1.4 cm (range 7 to 12 cm). No hospital death or morbidity was observed. All patients had arterial conduits: LIMA in 20 patients, RIMA in 3, RGEA in 4, and RA in 1. The mean number of grafts per patient was 1.3 +/- 0.6 (range 1 to 3). No blood transfusion was required perioperatively. The patency rate was 96%. All patients were in New York Heart Association class I and no wound complications or postoperative pain occurred during follow-up. CONCLUSIONS: Our experience demonstrates that the LESS approach for MIDCAB is technically feasible for revascularizing not only the LAD but also the RCA system, with the same small incision using IMA and GEA. It can be used with excellent cosmetic results and safety. Although our experience is limited, we conclude that this less invasive surgical technique can be used as an alternative approach for MIDCAB in patients with LAD or RCA disease.

Aged↗
PubMed2002

Incidental finding of myeloproliferative disorders during sternotomy.

We report 2 cases of myeloproliferative disorders discovered incidentally at the time of routine coronary bypass surgery. Suspicion of abnormal bone marrow tissue upon performing sternotomy and subsequent sampling for frozen section made the diagnosis. The surgical plan was changed, and partial revascularization without cardiopulmonary bypass was performed.

Aged↗
PubMed2002

Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy.

BACKGROUND: It remains controversial whether transcervical thymectomy offers results equivalent to thymectomy by way of a median sternotomy in the treatment of myasthenia gravis. Furthermore, preoperative prognostic factors have not been clearly defined. METHODS: This study is a retrospective chart review and interview of 78 patients completing transcervical thymectomy for myasthenia gravis between 1992 and 1999. RESULTS: There were 24 men and 54 women. Mean age was 40 years (range, 13 to 78 years). Twelve patients were in Osserman class 1, 25 in class 2, 30 in class 3, and 11 in class 4 (mean, 2.5). There was no perioperative mortality and 6 (7.7%) morbidities. Mean length of stay was 1.5 days and mean follow-up, 54.6 months. The crude cumulative complete remission (asymptomatic off medications for 6 months) rate was 39.7% (n = 31). Only 8 patients (10.3%) failed to improve after transcervical thymectomy. Kaplan-Meier estimates of complete remission were 31% and 43% at 2 and 5 years, respectively. Eight patients with thymoma had a 5-year estimated complete remission rate of 75% in contrast to 43% in 38 patients with thymic hyperplasia and 36% in 32 patients with neither thymoma nor hyperplasia (p = 0.01). Twelve patients with ocular myasthenia had a 5-year estimated complete remission rate of 57%, whereas patients with mild-to-moderate (n = 55) or severe (n = 11) generalized symptoms had 5-year complete remission rates of 43% and 30%, respectively (p = 0.21). CONCLUSIONS: Overall, extended transcervical thymectomy offers results that are comparable to those published for the transsternal procedure. Patients with milder disease (including isolated ocular disease) and taking no preoperative immunosuppressive agents appear to experience higher remission rates. In contrast to previous studies, we also find that small thymomas predict better responses to thymectomy.

Adolescent↗
PubMed2002

Arch-first technique for aortic arch aneurysm repair through median sternotomy.

We describe a modified arch-first technique for total arch replacement through median sternotomy. This technique involves a short period of circulatory arrest (less than 30 minutes) and subsequent anterior cerebral perfusion. It does not require cannulation of the carotid vessels, which can cause cerebral thromboembolism, and it enables anterior cerebral perfusion to be resumed after a relatively short period of circulatory arrest. This appears to be a useful technique to reduce cerebral complications in complicated arch reconstruction operation for patients with severely atherosclerotic carotid vessels.

Aorta, Thoracic↗
PubMed2002

Median sternotomy and extended left anterior thoracotomy for repair of traumatic aortic transection with ruptured right atrium.

A 22-year-old man presented with traumatic aortic transtion associated with rupture of the right atrium and underwent urgent median sternotomy to repair the right atrium. A T-shaped extended left anterior thoracotomy was performed, and ruptured descending thoracic aorta was repaired under total bypass. A Y-shaped connector was inserted in the arterial catheter to allow cannulation of both ascending aorta and femoral arteries. A 4-cm long Hemoshield graft was used to repair the aortic transection. The patient made a full recovery and was discharged 13 days after the accident.

Accidents, Traffic↗
PubMed2002

Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure.

BACKGROUND: Endovascular stent grafting through a median sternotomy for a distal arch aneurysm (the frozen elephant trunk procedure) is an alternative to synthetic graft replacement. But spinal cord dysfunction can easily occur as a complication after surgery. Although its cause is uncertain, some attempts at prevention have been instituted. We address the mechanism of spinal cord dysfunction and evaluate the efficacy of our preventive measures. METHODS: There were 22 men and 2 women with an average age of 71 (59 to 83) years. There were 22 true aneurysms (13 fusiform, nine saccular), one chronic dissection, and one penetrating aortic ulcer. The following strategies for prevention of spinal cord dysfunction were utilized: low flow perfusion through both axillary arteries (n = 10); pigtail catheter guidance (n = 19); use of a shorter graft with anchoring sutures (n = 12); flooding of the operative field with carbon dioxide (n = 7); aortic unclamping (n = 7), and use of ultra-thin woven Dacron grafts (n = 15). RESULTS: There was no operative mortality, but cerebrospinal dysfunction complicated four cases (17%): one paraplegia, one stroke along the basilar artery, and two cases of temporary spinal cord dysfunction (paresthesia of the right leg and urinary disturbance). Cerebrospinal dysfunction tended to occur in fusiform aneurysms (31%, p = 0.044). Except when low flow antegrade perfusion through both the axillary arteries was utilized, which resulted in no cases of paraplegia or paraparesis (p = 0.064), the methods used for prevention of cerebrospinal dysfunction appeared to have little efficacy. CONCLUSIONS: Cerebrospinal dysfunction is a serious complication of the frozen elephant trunk procedure. Its cause has not been clarified, but it tends to occur in fusiform-type aneurysms. Antegrade perfusion through both axillary arteries while the aorta is open may be helpful in its prevention.

Aged↗
PubMed2003

Mitral valve surgery and acute renal injury: port access versus median sternotomy.

BACKGROUND: Many outcomes and complications of minimally invasive and conventional cardiac surgery await comparison. Patients undergoing mitral valve surgery commonly sustain renal injury. Using peak postoperative fractional change of serum creatinine as a marker of renal injury, we tested the hypothesis that mitral valve surgery with port access minithoracotomy (Port) and conventional surgery with a median sternotomy (MS) incision are associated with different degrees of acute renal injury. METHODS: We evaluated data from all isolated mitral valve operations by a single surgeon between 1990 and 2000 (MS = 90, Port = 227). We also performed a secondary analysis of mitral valve surgeries performed by both MS and Port approaches in a concurrent period from 1996 to 2002 (MS = 93, Port = 240). Univariable and multivariable tests were used to determine the association of surgical technique with peak postoperative creatinine (CrmaxPost) and peak postoperative fractional change in creatinine (%deltaCr); p less than 0.05 was considered significant. RESULTS: In our analysis that accounted for the date of surgery, we observed a highly significant independent association between surgical approach and %deltaCr, indicating a greater risk of acute renal injury in the MS group (F value 13.33; p = 0.0003). Similar findings were noted in the secondary (time-concurrent) analysis of %deltaCr (F value 12.65; p = 0.0176). CONCLUSIONS: We present retrospective evidence of reduced acute renal injury associated with the port access technique in mitral valve surgery patients. Our findings suggest that a port access minithoracotomy approach to mitral valve surgery may be preferable to conventional methods for patients with high renal risk.

Acute Kidney Injury↗
PubMed2003

Total aortic arch grafting via median sternotomy using integrated antegrade cerebral perfusion.

BACKGROUND: In aortic arch grafting, antegrade cerebral perfusion prolongs the safe time of arch exclusion. However, there are the problems of cerebral embolism and distribution of the cerebral perfusion. We describe and analyze mortality and cerebral complications in patients undergoing total arch grafting using our refined technique. METHODS: Between June 1994 and March 2002, 100 consecutive patients underwent total arch grafting through median sternotomy. There were 49 atherosclerotic aneurysms and 51 aortic dissections. Fifty-four patients were operated on an emergency basis because of rupture or acute type A dissection. We conducted total arch grafting using hypothermic antegrade cerebral perfusion from every cervical vessel. Carbon dioxide gas was added to the cerebral perfusion in order to inhibit the increase in the cerebral vascular resistance during hypothermic cerebral perfusion. RESULTS: Hospital mortality was 4%. The causes of death were dysarrhythmia (n = 1), mesenteric necrosis (n = 1), and preoperative cardiac arrest (n = 2). On univariate analysis, preoperative shock and concomitant cardiac procedures were risk factors for hospital death. The rate of postoperative neurologic damage was 5%. Two patients suffered from cerebral infarction. Temporary neurologic dysfunction occurred in 3 patients. On univariate analysis, emergency surgery was a risk factor for postoperative neurologic damage. On multivariate analysis, there was no significant independent predictor of hospital mortality and neurologic damage. Actuarial survival at 96 months was 66.4 +/- 9.1%, and freedom from aortic accidents (reoperation, rupture, and cholesterol embolism) was 74.9 +/- 7.9%. CONCLUSIONS: The early- and long-term results of total arch grafting using integrated antegrade cerebral perfusion were found to be satisfactory.

Aged↗
PubMed2003

Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results.

BACKGROUND: We analyzed our 22 years of experience with extraanatomic bypass grafting for repair of aortic arch coarctation in adults. Results from early and midterm follow-up with clinical evaluation and magnetic resonance angiography are reported. METHODS: Between November 1979 and December 2001, 18 consecutive patients aged 18 to 61 years (mean, 31.8 +/- 13.3 years) underwent extraanatomic bypass grafting to repair coarctation of the aortic arch. Six patients (33.3%) had recoarctation after previous repair through a left thoracotomy, and 3 (16.7%) had associated cardiac diseases. The operative technique used in all patients was ascending aorta-to-descending thoracic aorta bypass with a polyethylene terephthalate fiber (Dacron) graft through a median sternotomy and posterior pericardial approach. RESULTS: Follow-up was completed in all patients, with a mean duration of 5.6 +/- 5.7 years (range, 12 months to 22 years). The follow-up interval exceeded 10 years in 5 patients. No neurologic complications, early or late mortality, late reoperations, or graft complications occurred. Six patients (33.3%) had mild hypertension. All patients were asymptomatic with patent Dacron grafts confirmed by echocardiography. Magnetic resonance angiography, performed in 15 (83.3%) patients, revealed that the Dacron grafts were still patent at a mean interval of 4.0 +/- 6.2 years (range, 5 days to 22 years) after repair. CONCLUSIONS: Extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic arch coarctation in adults is safe, with low morbidity and no mortality. The favorable midterm results indicate this technique is a safe and less invasive means of repairing aortic arch coarctation or recoarctation in adults.

Adolescent↗
PubMed2004

T-modification of sternotomy to accommodate a low-lying tracheostomy.

A low-lying tracheostomy can complicate a sternotomy for coronary artery bypass grafting. A modified "T" exposure, transecting the manubrium at the first intercostal space, can be utilized to maintain sternoclavicular architecture and avoid injury to the tracheostomy at the sternal notch.

Humans↗
PubMed2004

Successful repair of aberrant right subclavian artery aneurysm combined with bicuspid aortic valve through a median sternotomy.

We report a case of a successfully repaired aberrant right subclavian artery aneurysm combined with bicuspid aortic valve using a multibranched vascular prosthesis. Approaching solely through a median sternotomy under cardiopulmonary bypass, hypothermic circulatory arrest, and selective cerebral perfusion, we performed a successful single-stage correction by aortic valve replacement, resection of aneurysm, and reconstruction of the right subclavian artery.

Aged↗
PubMed1985

A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures.

Sternal wound infections developed following 77 (0.97%) of 7,949 operative procedures involving median sternotomy at New York University Medical Center from 1976 to 1984. Risk factors associated with the development of a sternal wound infection included combined revascularization and valve replacement, early reexploration for bleeding, prolonged low cardiac output syndrome, and prolonged ventilatory support (greater than 24 hours). Concomitant infection at other sites with the same organism as cultured from the sternum was present in 42% of the patients. Thirty-seven patients (48%) were treated with radical debridement followed by closed antibiotic irrigation. In 31 other patients (40%), the wounds were debrided and left to heal by open granulation. Both initial treatments had equally high success rates (78.4% and 74.2%, respectively). However, the open granulation method resulted in a hospital stay that was an average of 10 days longer than the closed antibiotic irrigation method. Muscle flaps were used to expedite healing of open granulation in 9 patients. Analysis of the results of different treatment strategies revealed that if debridement was accomplished within 20 days of the initial cardiac procedure, 76% of the patients could be successfully treated with closed antibiotic irrigation. Conversely, if treatment was delayed for longer than 20 days, 81% of the patients were treated with open granulation (p less than 0.001). Also noted was an inverse relationship between the serum blood urea nitrogen (BUN) level and the success rate of initial treatment with closed antibiotic irrigation. Patients with a serum BUN level of less than 40 mg/dl at the time of debridement had a 90% success rate as opposed to a success rate of 38% when the BUN level was 40 mg/dl or greater. The data presented suggest the following conclusions. Early diagnosis is crucial to successful treatment of sternal wound infection. When diagnosis can be established within 20 days, 80% of infections can be eradicated by the simple approach of debridement and closed antibiotic irrigation. When diagnosis is delayed, however, prompt debridement followed by muscle flaps is the procedure of choice. Open granulation alone, while successful, unnecessarily prolongs the hospital course.

Adult↗
PubMed1983

The importance of one-stage median sternotomy and retroperitoneal node dissection in disseminated testicular cancer.

More than 350 patients with testicular germ cell cancer have been treated with cisplatin combination chemotherapy. Seventy-two with metastases to the thorax who had operation are discussed here. In a subgroup of 24 patients with additional retroperitoneal disease, a one-stage median sternotomy was performed in 18 patients, and a thoracotomy in 6, with retroperitoneal node dissection. Seventeen patients had similar pathological lesions in the thorax and retroperitoneum; in 7, the lesions differed. There was no operative mortality in the entire group. Overall, chemotherapy altered the metastases to mature teratoma in 28 patients, and 27 are long-term survivors. Among 22 patients with fibrotic, necrotic masses, 19 are long-term survivors; 6 of the 22 with persistent carcinoma had chemotherapy postoperatively and are long-term survivors. The overall cure rate for patients with disseminated testicular cancer is approximately 80%. Among those who had a one-stage thoracoretroperitoneal procedure, long-term survival is 83%; for the entire thoracic surgical group, it is 74%.

Adolescent↗
PubMed1982

Upper extremity neuropathies following median sternotomy.

The status of 958 patients who underwent median sternotomy between January, 1978, and May, 1981, was analyzed. Fifty-four patients had an upper extremity neuropathy. Among 38 patients who underwent further evaluation, motor and sensory nerve conduction studies localized the injury to the level of the elbow in 13, to the brachial plexus in 10, and to both locations in 6. Ninety-two percent of these 38 patients were asymptomatic 3 months after operation.

Arm↗
PubMed1981

The embolization of bone wax from sternotomy incisions.

We discuss our study on the effects of discontinuation of the usage of bone wax as a hemostatic agent in sternotomy incisions. In 1976, we abandoned use of bone wax because it was suspected of causing several cases of Mycobacterium fortuitum sternal osteomyelitis. In a retrospective study involving 400 patients, we found that this step did not increase postoperative bleeding as measured by drainage from the chest tube and by the need to return patients to the operating room because of bleeding. It also was observed that there was an appreciable simultaneous drop in pulmonary complications. To test our theory that the wax pressed into the bone marrow can embolize to the lung, radioactively tagged bone wax was pressed into the cut sternum in animal models, and a search was made for radioactive deposits in the peripheral lung tissue. Shortly after the application of the wax, there was evidence of large radioactive deposits in the lungs. It is probable that this embolization occurs also under clinical conditions and may play a role in pulmonary complications following open-heart operations.

Animals↗
PubMed1985

Delayed closure of the median sternotomy incision.

Attempts to close a median sternotomy incision in the patient with profound cardiac or pulmonary dysfunction following a cardiac surgical procedure can result in severe hemodynamic deterioration. Delayed sternal closure in this setting may be a lifesaving technique. A method is described for delayed sternal closure that employs a temporary impermeable rubber patch sutured to the presternal fascia.

Aged↗
PubMed1986

Reconstruction of the infected median sternotomy wound.

Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.

Adult↗
PubMed1984

Occult rib fractures and brachial plexus injury following median sternotomy for open-heart operations.

The incidence and the sites of rib fractures during open-heart operations through a median sternotomy incision were studied in 36 consecutive patients divided into two groups. In Group 1 (24 patients), a conventional Ankeney retractor was used to expose the heart, and in Group 2 (12 patients), a similar retractor was used but with its uppermost pair of blades removed. Thorough physical examinations and preoperative and postoperative chest roentgenograms were obtained, and postoperative bone scans were done in all patients. No rib fractures were detected on the routine chest roentgenograms in patients in either group. Bone scans, however, showed 44 rib fractures (15 of the first rib, 13 of the second rib, 4 of the third rib, 6 of the fourth rib, 3 of the fifth rib, and 3 of the sixth rib) in 16 patients in Group 1. Six patients in Group 2 had 9 rib fractures (2 of the first rib, 4 of the second rib, and 1 each of the third, fifth, and sixth ribs). None of the patients in Group 2 had brachial plexus injury and neither of the first rib fractures in this group were located posteriorly, whereas 3 patients in Group 1 had both brachial plexus injury and posterior first rib fractures.

Brachial Plexus↗