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PubMed2003

The clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery.

BACKGROUND: Minimally invasive cardiac surgery is now becoming standard in the correction of simple congenital cardiac malfbrmations. We introduced a clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery, and assessed the function of the pathway in children with atrial or ventricular septal defects, comparing minimally invasive surgery to repair through a conventional full sternotomy. METHODS: We studied 15 children of school age who underwent repair of an atrial or ventricular septal defect through a lower midline sternotomy, and 10 children undergoing repair through a full sternotomy. The clinical pathway was for extubation to take place in the operating room, echocardiographic evaluation on the 5th postoperative day, and discharge home on the 7th postoperative day, with return to school within 2 weeks, and resumption of all gymnastic activity within 6 weeks of the minimally invasive surgery. RESULTS: In those having a lower midline sternotomy, postoperative hospital stay was 7.4 +/- 0.8 days, with return to school 8.0 +/- 2.4 days after discharge. They resumed gymnastics 41 +/- 11 days after the minimally invasive surgery. In those having a full sternotomy, in contrast, these parameters were 13.5 +/- 2.7, 23.1 +/- 8.4, and 95 +/- 43 days, respectively. Of the 15 children undergoing a minimally invasive approach, 12 (80%) fulfilled the criterions of our clinical pathway. CONCLUSIONS: We conclude that minimally invasive cardiac surgery can safely be performed in children. In addition to its cosmetic role, the technique has added value in promoting early return to normal school life, including gymnastics.

Adolescent↗
PubMedDate not supplied

Closure of atrial septal defects: is there still a place for surgery?

BACKGROUND: The purpose of this study is to assess the current management of atrial septal defect closure in an era of increasing feasibility of transcatheter device occlusion. METHODS: Atrial septal defect (ASD) closure was performed surgically through complete sternotomy in 165 patients (group 1) and through partial inferior sternotomy in 53 patients (group 2). Transcatheter device occlusion was achieved in 82 patients with only ASD type II and patent foramen ovale (group 3). RESULTS: Overall complications were minor and more frequent in group 1: 26.7% versus 13.2% in group 2 and 14.6% in group 3 (p = 0.04). Compared to complete sternotomy, a partial sternotomy led to less chest tube loss (7.1 +/- 2.9 versus 11.6 +/- 14.5 ml/kg) (p < 0.05) and less postoperative pericardial effusion (11.3% versus 13.5%)(p = 0.55). ASD closure was effective in 99.4% in group 1, 100% in group 2 but only in 86.6% in group 3 (p < 0.05). Two major complications of device implantation required early surgery: 1 femoral arteriovenous fistula and 1 device embolization. Hospital stay was significantly shorter in group 3, as well as in group 2 compared to group 1 (8.3 +/- 4.2 versus 5.9 +/- 1.1 versus 2.1 +/- 7.3 days) (p < 0.05). Midterm results were excellent, with only 1 non-cardiac death and 1 re-operation for residual shunt in group 1, and 1 device removal for thrombosis in group 3. CONCLUSION: Transcatheter device occlusion has become an established treatment for ASD closure, achieving optimal results in older children and adults with anatomically suited ASD type II and PFO. However, a partial inferior sternotomy offers a valuable and complementary operative approach for all ASD variants, maintaining the predictable success of surgery, with the obvious advantages of minimal access in terms of morbidity, cosmetics and hospital stay.

Adolescent↗
PubMed2002

Evolving techniques for mitral valve reconstruction.

OBJECTIVE: To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA: MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS: Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS: Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS: These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques.

Adult↗
PubMed2002

Preoperative magnetic resonance imaging screening for a surgical decision regarding the approach for anterior spine fusion at the cervicothoracic junction.

STUDY DESIGN: In a study investigating the correlation between a set of designed criteria and judgments of surgical experience, 100 cervical magnetic resonance images from different patients were used. OBJECTIVES: To demonstrate reliable and reproducible anatomic measurements that can aid spine surgeons in selecting surgical approaches for anterior spine fusion in the cervicothoracic region. SUMMARY OF BACKGROUND DATA: Surgical approaches to the cervicothoracic junction vary among surgeons. Whereas sternotomy provides maximum exposure, less extensive approaches are preferred to minimize surgical trauma, provided surgical goals are not compromised. No quantitative criteria currently exist to determine before surgery the least invasive surgical approach for sufficiently exposing pertinent anatomy. METHODS: Thirteen geometric variables designed to be clinically practical and to expose important anatomic relations were used to evaluate 100 sagittal scout cervical magnetic resonance image sequences. An experienced spine surgeon independently rated each image for the most appropriate surgical approach to the C5-T2 region. The ratings were tested for interrater reliability using a second spine surgeon. After testing for interrater and intrarater reliability, the geometric measurements were correlated with the surgeon's selected surgical approaches for each intervertebral segment (P < 0.05). RESULTS: Instrument manubrial thoracic distances, reflecting standardized heights of intervertebral discs above or below the superior tip of the manubrium, were the most reliable, reproducible, and correlative with the choice of surgical approach. All the measurements but one, the instrument manubrial thoracic distance for T1/T2, demonstrated interrater and intrarater reliability, with an interclass correlation of at least 0.70. The primary surgeon-investigator indicated the anterior approach with sternotomy (n = 3) or the transverse cervical approach (n = 97) for the C7/T1 exposure, and the anterior approach with sternotomy (n = 43) or the transverse cervical approach (n = 57) for the T1/T2 exposure. The interrater questionnaire reliability results indicated statistical agreement between the primary surgeon-investigator and the second cervical spine surgeon at all vertebral segments evaluated. Instrument manubrial thoracic distances showed the strongest significant correlation with the surgical approach, demonstrating a statistical power of 1. For the C7/T1 exposure, the instrument manubrial thoracic distance for C7/T1 was 1.9 +/- 2 cm (95% confidence interval [CI] = 1.41 to 2.22) for the transverse cervical approach, and -3.3 +/- 1.3 cm (95% CI = -4.79 to -1.75)] for the anterior approach with sternotomy. The instrument manubrial thoracic distance measurements for C5/C6, C6/C7, and T1/T2 also showed nonoverlapping 95% confidence intervals for the transverse cervical versus the anterior approach with sternotomy for the C7/T1 exposure. For the T1/T2 exposure, all four instrument manubrial thoracic distance measurements again showed statistically significant differences between approaches, with nonoverlapping 95% confidence intervals and a statistical power of 1. In addition, the measurements elaborating the anterior-to-posterior distance of the thoracic outlet and the measurements of the angle between the planes of the intervertebral disc and the sternum also showed statistically significant differences between approaches for the T1/T2 segment, with a statistical power of at least 0.9. CONCLUSIONS: Strong correlations exist between objective measurements and the choice of surgical approach for anterior spine fusion. Among investigated anatomic relations, the instrument manubrial thoracic distance correlated most reliably with the surgeons' choice of the anterior approach. Such objective measurements represent tools that cervical spine surgeons can use to determine the surgical approach.

Cervical Vertebrae↗
PubMed2004

Assessment based on EuroSCORE of ministernotomy for aortic valve replacement.

To assess the advantages of a ministernotomy over a standard sternotomy for aortic valve replacement, 191 patients were classified as low-, medium-, and high-risk by EuroSCORE. A ministernotomy was carried out in 100 patients, and a standard sternotomy was used in 91. Among low-risk patients, those who had a ministernotomy showed a marginal increase in atrial fibrillation. Of the medium-risk patients, those who had a sternotomy had significantly more atrial fibrillation and slightly more general infections. In the high-risk subgroup, significantly more atrial fibrillation was observed in the sternotomy group, and more neurologic events were observed in the ministernotomy group; the difference became nonsignificant when only severe events were considered. There was a significant benefit in terms of rhythm disturbances in medium- and high-risk patients who underwent a ministernotomy compared to those who had a full sternotomy. Mortality, duration of intensive care, and hospital stay were not influenced by the operative method.

Aged↗
PubMed1999

Minimally invasive aortic valve replacement (AVR) compared to standard AVR.

OBJECTIVES: Minimally invasive cardiac surgery has been developed to offer patients the benefits of open heart operations with decreased pain and limited skin incision. A limited superior median sternotomy has been shown to provide a good exposure for aortic valve replacement (AVR) and good results. In this study we report the results of minimally invasive AVR compared to standard sternotomy AVR performed in the same period. METHODS: From May 1996 to January 1998, 86 patients received isolated aortic valve replacement by the limited superior median sternotomy(group 1). As a control group (group 2), 78 patients were enrolled who underwent isolated aortic valve replacements by standard sternotomy in the same period. RESULTS: Median ischemic time and median bypass time between the two groups showed no significant difference (P > 0.05). Median entire operation time in group 1 was obviously shorter than that in group 2 (P < 0.01). Median postoperative drainage was 229 ml in group 1, 369 ml in group 2. The difference between the two groups (P < 0.05) was significant. Median postoperative respiratory support time was 7.43 h in group 1, 11.26 h in group 2, with significant difference (P < 0.05). Median duration of hospital stay were 6.2 days in group 1, 9.4 days in group 2, with significant difference (P < 0.01). Reoperations for bleeding were two in group 1, four in group 2, superficial wound infection and sternum disruption occurred once in group 1 and four times in group 2. There were two hospital deaths respectively in the two groups (not procedure related). CONCLUSIONS: The limited superior median sternotomy provides good exposure to the left ventricular outflow tract, aortic valve, ascending aorta, and even to the mitral valve through the roof of the left atrium. Therefore it seems to be suitable for all kinds of aortic valve operations. Besides less pain, shorter skin incision, shorter respiratory support time and lower blood loss, it has more advantages as opening and closure of the sternum is faster; decreasing infection and disruption of the sternum, and finally decreasing the time required for hospitalization and recovery.

Adult↗
PubMed2000

Primary closure of deep sternal wound infection following open heart surgery: a safe operation?

BACKGROUND: Deep median sternotomy wound infection is a significant source of morbidity and mortality after cardiac operations. Management of an infected median sternotomy incision is a subject of controversy. The aim of this study was to assess our experience with primary closure without any irrigation system for infected deep median sternotomy wound. METHODS: Between January 1994 and December 1997, 4,227 consecutive open heart procedures via a median sternotomy under cardiopulmonary bypass were performed in our department. A total of 27 (0.64%) consecutive patients with deep sternotomy wound infection were identified. The mean age of the patients was 45 years. Six were female and 21 were male. RESULTS: The incidence of deep sternal wound infection was therefore 0.64%. The mean duration between the primary operation and the onset of deep sternal wound infection was 2.5 weeks. Staphylococcus aureus and Staphylococcus epidermidis were the most common pathogen causing postoperative mediastinal infection. Out of the 27 cases, 17 were successfully treated, 8 (30%) died and 2 had a persistent fistula. The mean follow-up time was 18 months (range 4 to 52 months). The mortality in the pediatric group was 4/8 (50%) and 4/19 (21%) in the adult group. The mortality for mediastinitis presenting before one week or after 4 weeks after operation was 63%. In contrast, the mortality for mediastinitis presenting after one week but before 4 weeks after operation was 17%. CONCLUSIONS: Mediastinitis after cardiac surgical procedures remains a devastating complication. Primary closure without irrigation-suction system should only be considered in selected patients.

Adolescent↗
PubMed2001

The preferred approach for mitral valve surgery after CABG: right thoracotomy, hypothermia and avoidance of LIMA-LAD graft.

BACKGROUND AND AIM OF THE STUDY: An alternative to avoid redo sternotomy in patients with patent left internal mammary artery-left anterior descending coronary artery (LIMA-LAD) grafts undergoing mitral valve surgery is right thoracotomy with moderate-deep hypothermia (approximately 20 degrees C) and fibrillatory arrest without aortic cross-clamping. Few reports exist which directly compare re-sternotomy and right thoracotomy. METHODS: Between July 1992 and February 2000, 47 patients (39 males, eight females; median age 66 years; range: 41-83 years; 41 in NYHA class III or IV) with patent LIMA-LAD grafts underwent mitral valve surgery. Thirty-seven patients were approached through a right thoracotomy with moderate-deep hypothermia (median 20 degrees C) and fibrillatory arrest (right thoracotomy group), and 10 were approached through a re-sternotomy, with aortic cross-clamping and cardioplegic arrest. The median ejection fraction was 42% (range: 20-71%). Univariate analysis was used to determine predictors of outcome, as well as to evaluate differences in characteristics between groups. RESULTS: Operative mortality (OM) and perioperative myocardial infarction for the entire cohort was 11% and 10%, respectively, and there were no inter-group differences. No preoperative characteristics were associated with OM. Two LIMA-LAD graft injuries occurred in the re-sternotomy group compared with none in the right thoracotomy group (20% versus 0%, p = 0.04). Transfusion requirements were also greater in the redo sternotomy group (median 7 versus 2 packed red blood cell units, p = 0.04). CONCLUSION: Right thoracotomy with moderate-deep hypothermia and fibrillatory arrest is the preferred approach for reoperative mitral valve surgery after coronary artery bypass grafting in the presence of patent LIMA-LAD grafts. These data suggest that this approach is associated with decreased incidence of LIMA-LAD graft injury, as well as reduced transfusion requirements.

Adult↗
PubMed1992

[Hemodynamics of coronary surgery patients following magnesium aspartate infusion].

Hypertension is a common phenomenon in patients undergoing aortocoronary bypass grafting. This hypertension increases myocardial oxygen consumption and can be prevented by application of vasodilators. A possible cause is activation of the renin angiotensin system. Magnesium is a potent vasodilator and has a beneficial effect after myocardial ischaemia. The study was performed to analyse the influence of magnesium infusion on the haemodynamic status and plasma renin activity in patients undergoing aortocoronary bypass grafting. METHODS. Eighteen patients (NYHA classification II-III) undergoing bypass surgery were divided into two groups, a magnesium and a control group. The magnesium group (n = 9) received 0.8 mEq/kg per h magnesium aspartate as an infusion for 15 min while still awake. After induction of anaesthesia, the magnesium infusion was reduced to 0.2 mEq/kg per h and stopped after aortic cannulation was completed. Plasma magnesium levels and concentrations within erythrocytes were measured. Anaesthesia was induced by flunitrazepam (0.01 mg/kg), fentanyl (0.005 mg/kg) and pancuronium (0.1 mg/kg). After intubation, patients were normoventilated with N2O/O2 = 1:1 and isoflurane (0.5-1.0 vol%). Additional doses of fentanyl (0.0025 mg/kg) were injected before the incision and before sternotomy. Mean arterial pressure, heart rate, cardiac index, total peripheral resistance, pulmonary vascular resistance, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, left ventricular stroke work index, right ventricular stroke work index, intrapulmonary shunt and plasma renin activity were evaluated at five predefined points: (1) prior to magnesium infusion; (2) after magnesium infusion; (3) 10 min following induction of anaesthesia under steady-state conditions; (4) after sternotomy; (5) after aortic cannulation. RESULTS. Concerning the haemodynamic parameters (MAP, RAP, PAP, PCWP) no significant difference between the two groups could be demonstrated. In the control group peripheral resistance (TPR) was higher following sternotomy and aortic cannulation than in the magnesium group. Magnesium prevented decrease of the cardiac index (CI) under steady-state conditions, during sternotomy and following aortic cannulation. Left and right ventricular stroke work indexes (LVSWI and RVSWI) were higher in the magnesium group. Plasma renin levels were not significantly different between the two groups. CONCLUSION. Patients undergoing cardiac surgery benefit from magnesium administration in the pre-bypass phase. Due to its vasodilating effect, magnesium lowers the output impedance of the left ventricle and improves cardiac pumping function. It opposes detrimental cardiovascular responses to sternotomy and following aortic cannulation. Also of importance is the advantageous effect of magnesium on cardiac arrest elicited by cardioplegia and for reactivation of the ischaemic myocardium.

Aspartic Acid↗
PubMed2005

Mitral valve surgery using the classical 'heartport' technique.

BACKGROUND AND AIM OF THE STUDY: Mitral surgery in selected patients using femoral cannulation, percutaneous retrograde cardioplegia and endoballoon aortic occlusion with a 4-5 cm thoracotomy is felt to carry a higher operative risk than sternotomy with conventional cannulation. Herein, the authors compared their experience of the first 117 'Heartport' (HP) patients with a computer-matched group of sternotomy approach surgical patients (SP) to assess operative risk and 30-day outcome. METHODS: Data were extracted from the authors' STS certified, audited database on 117 patients based on an intention to treat. Between December 1997 and December 2004, a total of 92 isolated mitral valve (MV) repair (HP-MVRpr) and 25 isolated MV replacement (HP-MVR) procedures was conducted using Heartport. The patients were matched 1:1 (by age +/-7 years, cerebrovascular disease, inotrope use, and ejection fraction +/- 5%) to a control SP group. Operative and 30-day outcomes were measured. RESULTS: No parameter showed any significant difference in 30-day outcome between the HP and SP groups, except for an increase in cross-clamp and perfusion times. Two patients in the HP-MVRpr group required conversion to sternotomy for repair of coronary sinus perforation, and one patient was repaired without conversion. Surgery in one HP-MVRpr patient was aborted due to limited aortic dissection, but successful repair was carried out later with a conventional approach. No patient required conversion to sternotomy for improved exposure of the operative site. CONCLUSION: Despite a longer cross-clamp time, 'classical' HP MV surgery can be performed with no increased risk compared to conventional MV surgery. Catheter and endoballoon complications were rare even in the early experience, and conversion to sternotomy was unusual and safely performed with this approach.

Adult↗
PubMed1988

[Effect of preoperative continuous nifedipine maintenance medication on hemodynamics and myocardial lactate extraction in coronary surgery patients].

The cardioprotective efficacy of preoperatively maintained long-term oral nifedipine application to 21 patients undergoing coronary artery bypass grafting (CABG) was investigated during fentanyl-N2O-anaesthesia. Two groups were defined at random; one group of patients receiving their normal morning doses together with the premedication, the other, who received the last nifedipine medication in the evening before surgery. Measurements where performed: 1. before induction of anaesthesia (reference value), 2. after induction, 3. at skin incision, 4. during sternotomy. There were no significant differences of hemodynamic parameters between the two groups. The hemodynamic parameters heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and coronary perfusion pressure (CPP) decreased after induction in accordance with the plasma-concentrations of epinephrine and norepinephrine in both groups and increased again during sternotomy with HR and CI remaining below and MAP and CPP rising above the reference value. The nifedipine-plasma-concentrations were significantly higher in the group with the morning dose and just within the minimal therapeutic range before and after induction of anaesthesia. But during skin incision and sternotomy the plasma levels fell below 10 ng/ml, i.e. below the therapeutic level. The incidence of myocardial lactate extraction values greater than 10% was highest immediately after induction of anaesthesia and lowest during sternotomy with one patient in both groups exhibiting negative lactate extraction as a symptom of myocardial ischemia. The results suggest that the preoperatively maintained oral nifedipine medication of 10-20 mg p.o. was not able to provide sufficiently high nifedipine-plasma-levels during sternotomy nor to improve the hemodynamic state in patients with CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, General↗
PubMed1995

[Hemodynamic response to pericardiectomy in the patients with constrictive pericarditis: with reference to surgical approaches and responses to exercise].

Between 1975 and 1994, we performed 20 pericardiectomies for 19 patients with constrictive pericarditis (CP) through a median sternotomy (13 cases), a left thoracotomy (2 cases), a median sternotomy combined with a left thoracotomy (4 cases) or a median sternotomy under ECC (1 case). One patient died from LOS at 1st POD due to myocardial failure. Pericardiectomy through a median sternotomy decreased RA pressure but PAW pressure did not decrease in some patients. On the contrary, pericardiectomy through either a left thoracotomy or a median sternotomy combined with a left thoracotomy decreased PAW pressure as well as RA pressure significantly. Responses to bicycle exercise demonstrated marked elevation of RA and PAW pressures even in a mild case of CP, so that the exercise testing seems to be useful for early detection of CP and evaluation of the operative results.

Adolescent↗
PubMed1998

[Open heart surgery in patients with a tracheostoma].

From April 1992 to May 1997 six patients underwent open heart surgery, who had tracheostoma at the time of operation. The sternum was divided completely in three patients whose tracheostoma lay highly on the neck, and it was cut transversely on the manubrium at the level of the first intercostal space, below which it was split longitudinally in two patients (partial median sternotomy). In one patient right anterolateral thoracotomy was used. There were no operative death and no complication related to infection. A left internal thoracic artery (LITA) was used successfully for a bypass conduit in two patients who underwent partial median sternotomy. Dissection of the proximal portion of the LITA through the second intercostal space prior to the sternotomy made the graft procurement feasible in this particular situation. In conclusion, full-length sternotomy is performable safely when the tracheostoma lies highly on the neck, and the partial sternotomy up to the midmanubrium is applicable, including LITA harvesting, even if it is just at the sternal angle.

Adolescent↗
PubMed2006

Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae.

HYPOTHESIS: Complications associated with thyroidectomy for intrathoracic goiters have been underestimated because of the lack of a precise definition of high-risk patients. DESIGN: Retrospective multicenter multinational review of medical records and radiographic images of patients who underwent thyroidectomy for intrathoracic goiters reaching the carina tracheae. Demographic, clinical, operative, anatomical, and pathological data were recorded. RESULTS: There were 35 patients (mean +/- SE age, 63 +/- 11 years) included in the study. In 4 patients, the goiter was asymptomatic; 10 patients had dysphagia, 24 patients had dyspnea, and 3 patients had superior vena cava syndrome. A median sternotomy was required in 12 patients and a right-sided thoracotomy in 1 patient. The mean +/- SE operative time was 145 +/- 72 minutes (range, 50-360 minutes). Transient hypoparathyroidism developed in 13 patients. Four patients experienced transient hoarseness, and 1 patient had permanent vocal cord paralysis. There were no significant differences between the proportion of patients who underwent or did not undergo sternotomy or thoracotomy regarding vocal cord dysfunction (2 [15%] of 13 patients vs 3 [13%] of 22 patients) or hypoparathyroidism (5 [38%] of 13 vs 6 [28%] of 22 patients). The mean postoperative hospital stay was 10 days (range, 2-84 days). Four patients required reoperation. Two patients died. Nine of 14 patients with thyroid glands weighing at least 260 g required sternotomy vs 3 of 14 patients with thyroid glands weighing less than 260 g (P = .02). Overall, 18 [52%] of 35 patients were discharged without any complication. CONCLUSION: Intrathoracic goiters reaching the carina tracheae carry a high unreported risk of sternotomy, postoperative complications, reoperation, and death.

Adult↗
PubMed1989

Antihypertensive and anti-ischemic effects of nicardipine and nitroprusside in patients undergoing coronary artery bypass grafting.

The efficacy of nicardipine vs nitroprusside in controlling hypertension after sternotomy was compared in 120 patients undergoing coronary artery bypass grafting and anesthetized with fentanyl (100 micrograms/kg). All had good left ventricular function and had been receiving long term oral beta-blocking therapy. Patients were randomly allocated to 1 of 3 groups: group C, the control (n = 40), received no vasodilator; group N (n = 40) received intravenous nicardipine at an initial rate of 3 micrograms/kg/min; and group S (n = 40) received intravenous nitroprusside at an initial rate of 1 microgram/kg/min. Vasodilator infusion was begun before surgery and infusion rates were adjusted to maintain systolic blood pressure between 80 and 120% of postintubation (baseline) values. Additional measurements were obtained before incision and after sternotomy. In groups N and S, arterial blood pressure was effectively controlled in all patients. Before the incision, pulmonary artery pressure decreased in group S and systemic vascular resistance decreased in groups N and S. After sternotomy, mean arterial pressure, heart rate, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index and rate-pressure product increased in group C. At this time, pulmonary artery pressure returned to baseline values in group S. In groups N and S, heart rate, cardiac index and rate-pressure product increased, but, compared with baseline values, systemic vascular resistance remained low after sternotomy. Ischemic changes were seen in the electrocardiogram in 11 patients (28%) in group C, 10 patients (25%) in group S and 4 patients (10%) in group N. The concentration of creatine phosphokinase MB was not significantly different in the first 24 postoperative hours in any group.

Aged↗
PubMed1994

The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor.

Median sternotomy has been the accepted approach for dealing with mediastinal tumors or bilateral pulmonary disease, but exposure to the lower lobes and to mediastinal tumors extensively involving a hemithorax is often limited. Based on the reported experience from double-lung transplantation, we explored the use of clamshell incisions for these difficult problems. From March 1991 to December 1993, we prospectively studied the utility of clamshell incisions in 90 patients for the following indications: bilateral pulmonary metastases (62 patients), primary lung carcinoma with mediastinal involvement (13 patients), primary tumors of the mediastinum (14 patients), and mesothelioma (1 patient). Bilateral anterior thoracotomies with a transverse sternotomy (clamshell incision) were employed in 71 patients and a unilateral anterior thoracotomy with partial or complete median sternotomy (hemiclamshell incision) was used in 19 patients. For closure, we used pericostal sutures and sternal wires, usually augmented by sternal K-wire stents or Steinmann pins to prevent sternal override. Exposure to all areas of the mediastinum, pericardium, pleura, and lung was excellent. Specifically, the clamshell incision afforded markedly better access to lower lobe disease and hemithoracic extension of mediastinal disease than that possible with median sternotomy. There were no deaths or significant morbidity, and all patients tolerated the incisions well without mechanical respiratory difficulties. There was one wound infection. There was no late sternal override and the cosmetic results were found to be excellent during a follow-up of 2 to 33 months. We conclude that clamshell incisions constitute an improved surgical approach for the management of bilateral pulmonary or combined pulmonary and mediastinal disease.

Bone Nails↗
PubMedDate not supplied

Respiratory mechanics in the open chest: effects of parietal pleurae.

To understand how the parietal pleurae affect the mechanical behavior of the human respiratory system after the chest wall is opened by median sternotomy, we studied 18 anesthetized/paralyzed patients immediately before coronary artery bypass grafting surgery. Elastances and resistances of the total respiratory system (ETr, Rrs) were calculated from measurements of airway pressure and flow during mechanical ventilation in the frequency and tidal volume ranges of normal breathing. Elastances and resistances of the lungs (EL, RL), chest wall (Ecw, Rcw) were also estimated from measurements of esophageal pressure. Data were collected in the closed chest, after median sternotomy with the parietal pleurae intact and after the left parietal pleura was opened for internal mammary artery harvest. After sternotomy with pleurae intact (n = 14), Ers did not change but Rrs decreased (p < 0.05). Ecw (including the contribution of the pleurae) was higher than in the closed chest (p < 0.05) while EL and RL were lower (p < 0.05); Rcw did not change. Opening the left pleura (n = 10) decreased Ers (p < 0.05), but Rrs did not change. We conclude that the chest wall/pleurae compartment offers significant impedance to lung expansion after sternotomy and rib retraction, unless one pleura is opened.

Adult↗
PubMed2004

Surgical patch closure of atrial septal defects.

BACKGROUND: Development of nonsurgical techniques for closure of atrial septal defects (ASD) has prompted reevaluation of current surgical outcomes with an emphasis on less invasive methods. METHODS: This retrospective review is based on a single surgeon's experience between July 1, 1988 and December 21, 2002 with 176 consecutive adult (n = 47) and pediatric (n = 129) surgeries, in which ASD was the primary anatomical diagnosis to ascertain current optimal methods and outcomes expected for surgical closure. Patch closure with pericardium was used in all cases. Surgical methods encompassed three phases. The first phase was defined by traditional sternotomy; the second phase involved a series of technical modifications to shorten incisions and reduce surgical trauma; the third phase consisted of standardized less invasive techniques based upon age and gender with "bikini line" incisions for adult females, limited median sternotomy for adult males, and mini-median sternotomy for children. All patients underwent echocardiography to assess ASD closure. RESULTS: There were no deaths. The most frequent perioperative complications were atrial fibrillation (adult 10%, pediatric 1.2%) and post pericardiotomy syndrome (adult 2%, pediatric 4.7%). All patients had secure and complete closure of ASDs with no residual shunts (trivial or otherwise) documented by echocardiography. No less invasive procedures required conversion. CONCLUSIONS: Surgical technique evolved from standard sternotomy to limited access incisions using modified cannulation techniques and incision locations determined by age and gender of the patient without deterioration in outcome quality. Both standard and less invasive surgical methods can achieve secure closure of the septum with biological patches, which are incorporated into the tissue structure of the heart and which are free from materials-related failure modes. Patient satisfaction is enhanced by utilizing the least invasive, least traumatic, and most cosmetically appealing techniques for access and cardiopulmonary bypass.

Adolescent↗