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PubMed2002

Conversion from ministernotomy to full sternotomy in aortic valve replacement.

Conversion (C) from ministernotomy (M.S.) to full sternotomy was necessary in 5% of the cases in a series of 100 patients consecutively operated for Aortic Valve Replacement (A.V.R.) Analysis of the demographics and surgical techniques indicate older age, aortic fragility, diffuse coronary disease, chronic renal failure and left vent insertion as contributing factors. Despite increased operative blood losses, extra-corporeal circulation (E.C.C.) times, intensive care unit (I.C.U.) stay and hospital stay, no mortality was observed in the conversion group, as compared to 4.2% mortality in the total ministernotomy (MS) population. Preoperative patients selection, avoidance of technical pitfalls, and knowledge of alternative surgical measures are suggested to further decrease the incidence of conversions.

Aged↗
PubMed1992

Ectopic thymoma: a case for median sternotomy for complete thymectomy.

Thymomas are normally found in the superior mediastinum or the upper part of the anterior mediastinum. We report a case of thymoma arising in the inferior aspect of the anterior mediastinum. This case illustrates that thymic tissue may be found low in the anterior mediastinum and supports the practice of a median sternotomy approach for thorough mediastinal exploration in all cases of thymectomy.

Aged↗
PubMed2003

Full-sternotomy off-pump versus on-pump coronary artery bypass procedures: in-hospital outcomes and complications during one year in a single center.

We prospectively compared, according to their preoperative clinical profiles, the in-hospital outcomes of patients operated on consecutively (but without randomization) for isolated coronary artery disease with on-pump or off-pump techniques. During 2001, 324 patients underwent coronary artery bypass grafting: 216 patients (mean age, 66.7 +/- 8.9 years; range, 41-85 years) underwent on-pump revascularization, and 108 patients (mean age, 676 +/- 10 years; range, 37-90 years) underwent full-sternotomy off-pump revascularization. The 2 groups were homogeneous with regard to female sex (22.6% vs 26.8%), previous cardiac operation (2.8% vs 4.6%), cardiogenic shock (1.3% vs 1.9%), diabetes (30% vs 33%), and chronic renal failure that required hemodialysis (3% vs 3.5%). Postoperative complications, including bleeding, myocardial infarction, acute renal failure, mediastinitis with sternal dehiscence, cerebrovascular events, and prolonged respiratory assistance were more frequent in on-pump patients (P = 0.004). The total number of grafts and the grafts per patient ratio were significantly higher in on-pump patients (P = 0.0001), whereas the total number of full arterial revascularizations was higher in off-pump patients (P = 0.0001). Off-pump patients showed a significantly shorter intensive care unit stay (P = 0.02), and less need for intra-aortic balloon pump insertion (P = 0.04). In-hospital mortality was 2.8% in on-pump patients and 2.7% in off-pump patients (P = NS). Although the hospital mortality rate was comparable for the 2 techniques, the in-hospital comparison between the 2 groups showed how the avoidance of cardiopulmonary bypass can significantly reduce the cumulative postoperative incidence of complications in patients undergoing coronary artery bypass grafting.

Adult↗
PubMed2003

Midterm results of beating heart surgery in 1-vessel disease: minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with full sternotomy.

BACKGROUND: Off-pump cardiac surgery is becoming an established method of surgical revascularization. However, performing anastomoses on a beating heart can be challenging, especially through small incisions. We compared our midterm results in patients with 1 vessel disease using full sternotomy (OPCAB) or a left anterior minithoracotomy (MIDCAB). METHODS: At our institution between December 1996 and December 1998, 102 patients (OPCAB, n = 45, MIDCAB, n = 57); age, 61 +/- 11 years; 69% men with 1-vessel disease of the left anterior descending coronary artery (LAD) underwent off-pump myocardial revascularization through the left internal thoracic artery (LITA). In the OPCAB group 17 (37.8%) of the patients received an additional vein graft to a diagonal branch. OPCAB was generally preferred in obese or high-risk patients or patients with a long LITA-LAD distance (>7 cm) on an electron beam computed tomography of the chest. RESULTS: Operative mortality was 0. Time of surgery (169 +/- 48 versus 197 +/- 45 minutes) and coronary artery occlusion time (19 +/- 7 versus 23 +/- 6 minutes) were significantly lower (P = .004 and P = .009) in the OPCAB group. MIDCAB surgery was related to a higher incidence of occluded (4 versus 0; P = .039) or stenosed (7 versus 2; P = .06) anastomoses and necessity for immediate reintervention (9 versus 0; P = .023). During a mean follow-up period of 5.2 years, MIDCAB patients (6 MIDCAB patients versus 1 OPCAB patient) tended to need more coronary interventions and develop more recurrent angina (23 MIDCAB versus 12 OPCAB patients). Two OPCAB patients died during the follow-up period. CONCLUSIONS: Our initial experience in beating heart surgery demonstrated that MIDCAB is technically more challenging than OPCAB. MIDCAB procedures should therefore be performed by experienced surgeons on selected patients. Midterm results after OPCAB procedures tend to a lower rate of adverse cardiac events.

Analysis of Variance↗
PubMed1992

Repair of hypoplastic or interrupted aortic arch via sternotomy.

Herein we describe our experience with repair of interrupted aortic arch and coarctation plus hypoplastic aortic arch in 55 consecutive infants (1984 to 1990). Median age at operation was 6 days and median weight 3.1 kg. Associated severe intracardiac anomalies were the rule. All patients had significant congestive cardiac failure, and the majority required prostaglandin E1 resuscitation and inotropic support (with or without ventilation) before the operation. All operations were performed via sternotomy with core cooling and circulatory arrest. Isolated myocardial perfusion was used in 13 patients during arch repair. A complete intracardiac (biventricular) repair was performed except in patients expected to require a Fontan operation as definitive treatment. The operative mortality overall was 14.5% (confidence limits 10% to 22%). For arch repair plus biventricular intracardiac repair, the operative mortality was 9% (confidence limits 5% to 15%), and for arch repair plus palliative intracardiac repair, 40% (confidence limits 22% to 60%). The mortality in the isolated myocardial perfusion group was 0% (confidence limits 0% to 14%), which may be related to reduced myocardial ischemic time (p less than 0.05). Actuarial survival was 75% (confidence limits 65% to 83%) at 12 months, with no subsequent deaths over 1294 patient-months (mean 28 months) of follow-up. Actuarial freedom from recurrent arch obstruction was 69% (confidence limits 48% to 85%) at 46 months' follow-up. Primary repair of interrupted aortic arch and coarctation plus hypoplastic arch compares favorably with a staged approach and is recommended even when complex intracardiac anatomy is present.

Aorta, Thoracic↗
PubMed2004

Iatrogenic left subclavian artery-to-left brachiocephalic vein fistula: successful repair without a sternotomy.

Subclavian vein catheterization can result in arteriovenous fistula formation--a rare complication that will eventually lead to heart failure if left untreated. The world medical literature describes several subclavian artery-to-subclavian vein fistulas and 2 subclavian artery-to-brachiocephalic vein fistulas, both on the right side. To our knowledge, there have been no reports of an iatrogenic left subclavian artery-to-left brachiocephalic vein fistula. We report a case in which this complication occurred after unsuccessful transvenous pacemaker placement. We treated the fistula with a simple surgical technique that avoided the need for a sternotomy. Although stenting is typically the procedure of choice for such fistulas, our technique is useful when stenting is not indicated.

Aged↗
PubMed1980

Wound complications after median sternotomy: A study of 61 patients from a consecutive series of 9,279.

Among a consecutive series of 9,279 sternotomies performed during a period of 2(1/2) years, 61 (0.66%) patients developed significant wound complications. Of these, 58 (95.1%) survived. Sternal infection occurred in 36 patients (0.39%). Predisposing factors included chronic obstructive pulmonary disease, diabetes mellitus, obesity, closed chest massage, prolonged assisted ventilation, and excessive bleeding after operation. Positive end expiratory pressure (PEEP) did not, in itself, predispose to sternal dehiscence. Intermittent positive pressure breathing (IPPB) treatments caused excessive coughing, which may have increased the likelihood of dehiscence. Disposable drapes and expeditious surgery probably contributed to the low incidence of wound infection. Early diagnosis, surgical debridement, rewiring and primary closure with substernal drainage, without continuous antibiotic irrigation, resulted in satisfactory resolution in most patients.

Journal Article↗
PubMed1992

Aneurysmal bone cyst of the upper thoracic spine. An operative approach through a manubrial sternotomy.

Surgical access to T-1 and T-2 vertebral bodies through standard cervical approaches may be difficult and extensive in patients with short necks or high sterna. Adequate exposure of this area can be achieved in children, using a partial manubrial sternotomy and retraction of the manubrial halves. This procedure was successfully performed in a 14-year-old girl whose T-1 vertebra had been completely replaced by a large aneurysmal bone cyst that had produced major paraparesis. A two-stage anteroposterior excision and spinal fusion resulted in complete restoration of neurologic function, eradication of the cyst, and stabilization of the cervicothoracic spine. The limited manubrial split approach to lesions in the T-1 and T-2 vertebrae is recommended.

Adolescent↗
PubMed1992

[A case report of surgical repair of aneurysm involving the distal arch and the descending aorta through median sternotomy].

A 46-year-old male patient with aneurysm involving the distal arch and the descending aorta was operated on successfully. Graft replacement of aneurysm with inclusion method was performed through median sternotomy with left pleurotomy. One month after operation, CT scan showed thrombus occupied between the graft and the aneurysm, and two years postoperatively, the aneurysm shrunk almost to normal size of the aorta. Therefore, our surgical procedure was considered to be proper.

Aorta, Thoracic↗
PubMedDate not supplied

Surgical management of substernal goitres. When is sternotomy inevitable?

PURPOSE: Aim of this retrospective study is to report personal experience in the surgical management of substernal goitres emphasizing the guidelines for preoperative planning of sternotomy in selected cases. PATIENTS AND METHODS: Medical records of all patients (n=355) submitted to thyroidectomy for struma in our Operative Unit, between 1993-2003, were analysed. A substernal goitre was defined as a goitre having a significant retrosternal extension (>50%) requiring mediastinal dissection. RESULTS: A total of 18 out of 355 patients undergoing thyroidectomy for struma in our Operative Unit had substernal goitres. The most common symptoms, at presentation, were the presence of neck mass and respiratory disorders. Standard cervical incision was adequate to achieve total thyroidectomy in 17 cases while, in one patient with computed tomography images showing the presence of a huge goitre extending below the aortic arch, a sternotomic approach was inevitable to ensure safe removal. No major morbidity or perioperative deaths occurred. One patient with scleroderma experienced bilateral paralysis of laryngeal nerves for two months, with full recovery thereafter. CONCLUSIONS: While removal of the majority of substernal goitres can be achieved by means of cervical incision, this approach is not always safe. In a selected number of cases with an iceberg shaped substernal goiter and with >70% of the volume lying below the thoracic outlet, a sternotomic approach is inevitable. Preoperative diagnostic work-up should, thus, include chest X-ray and computed tomography. Overall results in the present patient population, have been excellent since morbidity has been minimal and mortality absent, and all patients are symptom free.

Adult↗
PubMed2005

Effective method to control catastrophic hemorrhage during redo sternotomy.

Redo sternotomy is a challenging surgical procedure performed with increasing frequency; catastrophic hemorrhage is a rare but highly lethal complication. We report our experience in treating this complication in 3 cases of 307 reoperations and propose a simple method to control catastrophic hemorrhage during sternal reentry.

Aged↗
PubMed2006

Alternative to sternotomy: aortic valve replacement through right thoracotomy.

Many minimally invasive alternatives to aortic valve replacement through full sternotomy have been described. We report an approach through a right thoracotomy that has been planified in 2 patients with contraindication to standard thoracotomy. Exposure was excellent, and valve replacement could be performed safely.

Aortic Valve Stenosis↗
PubMedDate not supplied

Traumatic right atrial disruption with hepatic and splenic injuries: treatment by CPB-assisted laparotomy and sternotomy.

The Authors present a case of thoracoabdominal trauma from a road accident in a young woman who received care initially in a level II hospital. She was then transferred to a level I Trauma Centre with the onset of haemorrhagic shock due to haemopericardium and haemoperitoneum from liver injuries. A chest CT scan led to the suspicion of aortic dissection, hence a cardiopulmonary bypass (CPB) for life support was instituted just before laparotomy through the femoral vessels. Exploration of the peritoneal cavity was performed as a first step because haemoperitoneum was deemed to be the main cause of shock. One litre of blood was aspirated and hepatosplenic tears were sutured to obtain haemostasis. Subsequently, aortic dissection was ruled out by median sternotomy, while a right atrial disruption was identified and repaired by stitches and a pericardial homologous patch. Nevertheless, the ascending aorta was explored by transverse arteriotomy. The postoperative course was uneventful and the woman has never presented cardiac or abdominal symptoms as a result of trauma or surgery.

Adult↗
PubMed1991

[A median sternotomy approach for symptomatic right subclavian artery in the adult].

A case of 33-year-old woman with aberrant right subclavian artery was reported. She was admitted to the hospital complaining of progressive dysphagia of six months' duration. The esophagogram revealed an oblique tubular defect in the superior thoracic esophagus. Aortograms confirmed the presence of an anomalous right subclavian artery arising as a fourth branch of the aortic arch, passing behind the esophagus in its course to the right arm. Operation was performed on Sept. 4, 1990. Through a median sternotomy, the ascending aorta and the two carotids were dissected free. With gentle forward retraction of the ascending aorta to the left, the origin of the aberrant right subclavian artery could easily be exposed. The right subclavian artery was then divided and its origin from the distal aortic arch oversewn. The vessel was removed from the retroesophageal position and blood flow reestablished to the right arm by an end-to-side anastomosis to the right carotid artery, using a temporary shunt tube. These procedures were accomplished without difficulty. Postoperatively, the patient made an uneventful recovery and was discharged 16 days after the procedure. A postoperative esophagogram confirmed the removal of the esophageal compression. The blood pressure was equal in the two upper extremities. In follow-up study, her symptoms had completely disappeared.

Adult↗
PubMed1991

[Post-sternotomy mediastinitis: strategy of treatment].

To determine the incidence, the mortality, the risk factors and the most appropriate method for treatment of sternal infections, 9,742 charts were reviewed retrospectively of patients having undergone a sternotomy for cardiac surgery at the Montreal Heart Institute. One hundred and eleven sternal infections (1.1%) were identified: 55 (0.57%) superficial, 56 (0.57%) profound (mediastinitis). The treatment for these profound infections was either debridement, open or closed with drainage irrigation, pectoral flap closure-repair, or epiplooplasty closure. The risk factors for those patients experiencing profound infections were diabetes, obesity, length of the surgical intervention, the time spent in the operating room, and the duration of endotracheal intubation. Eleven of the 111 patients died. The average length of hospitalization were similar for those patients treated by pectoral flap repair and by the epiplooplasty closure. All patients (100%) treated by the epiplooplasty closure developed an epigastric hernia. Six cases of recurrent infection were observed in the group treated by debridement. The average hospital stay was shortened for those patients benefiting from the pectoral flap and epiplooplasty closures. A high incidence of mortality is associated with profound sternal infection. The methods of treatment are various. We recommend as treatment of choice, the pectoral flap closure because there is relatively low risks with this procedure, little to no recurrence of infection, a shorter hospital stay and this procedure does not provoke epigastric hernia.

Adult↗