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PubMed1992

Results of a multidisciplinary strategy for management of mediastinal parathyroid adenoma as a cause of persistent primary hyperparathyroidism.

Persistent primary hyperparathyroidism due to mediastinal parathyroid adenoma was effectively treated by either angiographic ablation or median sternotomy in this study of 49 patients managed at the National Institutes of Health since 1977. Each patient presented here with symptomatic persistent primary hyperparathyroidism after failed initial surgical procedures done at other institutions. Each patient underwent extensive parathyroid localization procedures, including selective angiography, and most had a parathyroid adenoma localized to the mediastinum. Angiographic ablation, the deliberate injection of large doses of contrast material into the artery that selectively perfuses the adenoma, was initially successful in 22 of 30 procedures (73%) in 27 patients. Long-term control of persistent primary hyperparathyroidism was achieved in 17 of 27 patients (63%) by angiographic ablation. Each unsuccessful ablation could be easily salvaged by surgical resection. Surgical resection of the parathyroid adenoma by median sternotomy achieved immediate success in 24 of 24 procedures (p2 less than 0.02 versus ablation), and long-term cure in 23 of 23 evaluable patients (p2 less than 0.001 versus ablation). However, ablation did have benefits for the patients in whom it was successfully performed. It was associated with a significantly shorter hospital stay (median, 6 days versus 9 days for sternotomy, p2 less than 0.003), much less pain, and easier recuperation. Complications of each procedure were transient and similar in both groups. Operative resection is the most effective single means to eradicate mediastinal parathyroid adenoma; however, angiographic ablation can provide similar long-term control of hyperparathyroidism in 63% of patients with less pain and shorter convalescence than that seen in patients after median sternotomy. Our results suggest that angiographic ablation should be attempted as the initial procedure for patients with persistent primary hyperparathyroidism caused by an angiographically identified mediastinal parathyroid adenoma. Operation can be reserved for those who fail ablation.

Adenoma↗
PubMed1993

Surgical approach of choice for penetrating cardiac wounds.

One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.

Adult↗
PubMed1995

Modified anterior approach to the cervicothoracic junction.

STUDY DESIGN: This study reports the experience with four patients regarding a modified anterior approach to the cervicothoracic junction. OBJECTIVES: This technique was evaluated with respect to extent of exposure, ease of technique, and postoperative morbidity. SUMMARY OF BACKGROUND DATA: Previously reported anterior approaches to the cervicothoracic junction have described either full sternotomy resection of the left sternoclavicular junction or osteotomy of the clavicle. A simplified approach was chosen using a partial sternotomy, which has not been described previously for approaches to the spine. METHODS: Four patients with metastatic disease, in the region of the cervicothoracic junction, required decompression and stabilization for palliation of symptoms. An anterior approach was required for decompression. A standard cervical approach was combined with a partial median sternotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum. In three patients, the left innominate vein was divided. Decompression and anterior stabilization were followed by posterior stabilization at an interval of 4 to 7 days. RESULTS: This procedure was simple to perform, requiring little additional operative time for opening or closure. It provided excellent exposure from C3-T4. There was no associated morbidity related to the division of the manubrium or innominate vein. CONCLUSION: Partial sternotomy combined with a standard cervical incision provides excellent exposure to the cervicothoracic junction from C3-T4. It is technically simple to perform and avoids the risk of injury to subclavian vessels inherent in resection of the clavicle or sternoclavicular junction. There is no additional morbidity associated with this approach.

Cervical Vertebrae↗
PubMedDate not supplied

Ventricular assist device implantation using a right thoracotomy.

Most patients needing implantation of a ventricular assist device (VAD) require repeated sternotomy; some after cardiac surgery, and others later for heart transplantation. The purpose of this study was to establish the right thoracotomy technique as an alternative for VAD implantation to reduce repeated sternotomy-related morbidity and mortality. We performed a right thoracotomy in animals, preclinical cadaver fitting tests, and a clinical case. A total of 20 various animals underwent right thoracotomy for implantation of bi-VAD (BVAD, n = 17) and left VAD (LVAD, n = 3). The right chest cavity was entered through the fourth intercostal space with partial resection of the fifth rib. There was no procedure-related morbidity or mortality, except for one calf with right anterior leg paralysis. Preclinical fitting tests were performed on 7 human cadavers to observe the anatomical feasibility of BVAD cannulation from the right side of the heart. In humans, the ascending aorta, interatrial groove, right atrium, and main pulmonary artery were identified as optimal cannula insertion sites for BVAD implantation. A patient with cardiogenic shock underwent a right thoracotomy for implantation of an external LVAD. Cardiac function recovered after 3 weeks, and the device was successfully explanted through a repeat right thoracotomy. In conclusion, a right thoracotomy can be an alternative method to the standard median sternotomy for patients who need repeated sternotomy because of previous cardiac surgery, transplantation at a later date, or those with mediastinal infections.

Aged↗
PubMedDate not supplied

Thoracotomy approach for congenital and acquired heart defects: its possible applications in the current era.

From April 1975 to February 1995, 305 patients (260 females and 45 males) underwent open heart surgical procedures through the thoracotomy approach. Their ages ranged from 4 months to 55 years (mean age 21.8 +/- 13 years). Two hundred and ninety-seven patients were operated through the right and eight through the left thoracotomy approach. Two hundred and sixteen patients had congenital heart disease and 89 patients had acquired heart diseases, which included ostium secundum defect (190 patients), sinus venosus defect (11 patients), partial atrioventricular (AV) canal defect (5 patients), complete AV canal (1 patient), ventricular septal defect (4 patients), Tetralogy of Fallot (3 patients), anomalous origin of left coronary artery from pulmonary artery (3 patients), mitral valve lesions (83 patients), including tricuspid valve lesions (5 patients) and coronary artery disease (2 patients). Postoperative recovery was observed to be faster (mean hospital stay 7.8 days vs mid-sternotomy 9.6 days), infection rate lower (0.35% vs median sternotomy 2.56%), postoperative drainage lower (148.8 +/- 86.2 mL vs median sternotomy 587 +/- 112.6 mL), and cosmetically found to be much more acceptable in the female population. There have been seven early and one late postoperative deaths which were unrelated to the operative approach. We conclude from this experience that thoracotomy can be safely used as an access for a wide variety of open cardiac surgical operations on the atrial and (upper) ventricular septae, AV valves, right ventricular outflow tract, and coronary artery reconstruction in some situations. It is also useful in some emergency and redo operations with distinct advantages over the median sternotomy approach. We feel its use should be increased as newer subsets of patient populations are being subjected to primary and redo cardiac operations.

Adolescent↗
PubMed2003

Comparison of different approaches for pediatric congenital heart diseases.

To compare the clinical results of different surgical approaches for congenital heart disease in pediatric patients, 1669 cases of atrial septal defect, ventricular septal defect, or tetralogy of Fallot, which were corrected from January 1999 to December 2001, were classified according to approach (sternotomy, ministernotomy, or minithoracotomy). In cases of ventricular septal defect, the incidence of pulmonary complications was significantly higher in the minithoracotomy group than in the full sternotomy or ministernotomy groups. In patients with tetralogy of Fallot, hemoglobin concentration was higher, oxygen saturation was lower, and more patients required a transanular patch in the sternotomy group than in the other groups, but the clinical results were similar. Patients with complex defects or severe pulmonary hypertension should undergo a full sternotomy.

Cardiac Surgical Procedures↗
PubMed1989

Control of intraoperative hypertension with isoflurane in patients with coronary artery disease: effects on regional myocardial blood flow and metabolism.

The effect of isoflurane on regional myocardial metabolism and blood flow, when used as an adjunct to fentanyl-nitrous oxide anesthesia, to control intraoperative hypertension was investigated. Twenty-two patients with two- or three-vessel coronary artery disease with an ejection fraction greater than 0.5 and on beta-blockers up to the morning of surgery were studied during elective coronary artery by-pass grafting. Systemic and pulmonary hemodynamics, and regional (great cardiac vein, GCVF) myocardial blood flow and myocardial metabolic parameters were measured. In 10 patients, both GCVF and global (coronary sinus, CSF) myocardial blood flows were recorded. Measurements were made 1) after induction of anesthesia but prior to skin incision, 2) during sternotomy, and 3) during isoflurane administration after its use to reduce arterial pressure to the presternotomy level. The increase in systemic arterial pressure during sternotomy was due to an increase in systemic vascular resistance accompanied by increases in heart rate, pulmonary capillary wedge pressure, (PCWP) regional myocardial oxygen consumption and extraction, GCVF and total coronary vascular resistance. Isoflurane reduced systemic arterial pressure but not PCWP, to presternotomy levels within 6.9 +/- 0.7 minutes at an end-tidal concentration of 1.5 +/- 0.2%. Isoflurane induced a pronounced systemic and coronary vasodilatation and increases in cardiac index, heart rate and regional myocardial oxygen extraction while the GCVF/CSF ratio remained unchanged. While mean regional--MLE% values were not effected by sternotomy, in two patients myocardial lactate production was seen during sternotomy but not during isoflurane. In another two patients, isoflurane induced lactate production.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Effects of thoracotomy on respiratory system, lung, and chest wall mechanics.

Nineteen rats were sedated, anesthetized, paralyzed, and mechanically ventilated. The respiratory, lung, and chest wall elastances (Est-rs, Est-L, Est-w); respiratory system, pulmonary, and chest wall total resistances (Rtot-rs, Rtot-L, Rtot-w); respiratory system, pulmonary, and chest wall initial resistances (Rinit-rs, Rinit-L, Rinit-w); and respiratory system, pulmonary, and chest wall difference resistances (Rdiff-rs, Rdiff-L, Rdiff-w) were determined before and after thoracotomy using the end-inflation occlusion method. Rinit reflects the Newtonian resistances and Rdiff represents the viscoelastic/inhomogeneous pressure dissipations in the system. Rtot = Rinit+Rdiff, ie, total resistance. The animals were submitted to either anterolateral thoracotomy (group A, n = 7), median sternotomy (group B, n = 6), or median sternotomy under PEEP while the lungs were exposed (group C, n = 6). In groups A and B, statistically significant increases in Rdiff-rs significantly augmented Rtot-rs. The former results were entirely secondary to significant increases in Rdiff-L, which naturally raised Rtot, L. Resistance was not altered in group C rats. Thus, anterolateral thoracotomy and median sternotomy increases Rtot-rs as a consequence of augmented Rdiff-L, but this finding could be prevented by the use of PEEP. Est-rs and Est-L increased in the three groups after surgery. Groups D and E were comprised of four animals each. Both underwent median sternotomy and in group E, PEEP was applied. Histopathologic examination of the lungs demonstrated a higher degree of lung collapse in group D.

Animals↗
PubMed2002

Sarcomeres are added in series to emphysematous rat diaphragm after lung volume reduction surgery.

STUDY OBJECTIVES: The diaphragm adapts to its shortened state in experimental emphysema primarily by losing sarcomeres in series, thus reducing its optimal operating length. One would expect improved diaphragmatic function after lung volume reduction surgery (LVRS) only if the muscle can readapt to its elevated, lengthened postoperative position by either adding back sarcomeres or lengthening sarcomeres. We used a model of elastase-induced emphysema in rats to test the hypothesis that sarcomere addition occurs following LVRS. DESIGN: A cohort of emphysematous rats was created by the intratracheal instillation of elastase. Five months after the instillation, one group of rats underwent measurement of in situ costal diaphragm length via laparotomy, the determination of optimal muscle fiber operating length (Lo) on stimulated diaphragm strips in vitro, and the measurement of sarcomere length by electron microscopy on strips fixed at Lo. Another group of rats underwent LVRS or sham sternotomy 5 months after the instillation, and 5 months following the operation these animals underwent the same series of diaphragmatic studies. RESULTS: Lo was significantly greater in rats that underwent LVRS than those that underwent sternotomy (mean [+/- SE] Lo after LVRS, 2.50 +/- 0.08 cm; mean Lo after sternotomy, 2.27 +/- 0.06 cm; p = 0.013). There was no significant difference in sarcomere lengths between the two groups (2.95 +/- 0.04 vs 3.04 +/- 0.04 microm, respectively; p = 0.10). Using Lo as the length basis, the mean sarcomere number was calculated to be 8,712 +/- 192 in animals that had undergone LVRS and 7,144 +/- 249 in animals that had undergone sternotomy (p < 0.001). CONCLUSION: Sarcomere length is not significantly altered but sarcomeres are added in series following LVRS in this experimental model of emphysema/LVRS. It is likely that this sarcomere addition is a prerequisite to the improvement in inspiratory muscle function that has been observed following LVRS in humans.

Animals↗
PubMedDate not supplied

Intercostal artery as a pedicled graft for myocardial revascularization: an animal experimental study.

An experimental study was conducted in 12 dogs to evaluate the technical feasibility of using the 8th and 9th intercostal arteries as pedicled grafts for myocardial revascularization. In phase 1 (n = 4), the technique to harvest the intercostal artery as a pedicled graft posteriorly based on the thoracic aorta was developed. In phase 2 (n = 4), the sternotomy approach was compared to posterolateral thoracotomy for access. Pedicles were routed to various coronary arteries via a pericardial window. In phase 3 (n = 4), evaluation was confined to the left 8th and 9th pedicles via median sternotomy approach, as this is more clinically applicable. Blood flows and external diameters were measured. Mid sternotomy approach to the 8th and 9th intercostal arteries on both the right and left was feasible and technically adequate grafts were obtainable. These pedicled grafts reached the branches of both the left circumflex and right coronary artery. Mean blood flows in the left 8th and 9th intercostal artery grafts were 25+/-2.58 and 27+/-2.1 mL/min with mean external diameters of 0.44+/-0.027 and 0.48+/-0.028 mm, respectively, and a mean body weight of 25 kg. We conclude that the 8th and 9th intercostal arteries can technically be harvested as pedicled grafts via median sternotomy and can be used to revascularize the left circumflex coronary system.

Animals↗
PubMed1998

[Minimally invasive cardiac surgery for aortic valve disease].

Recent surgical advances leading to good operative results have contributed to the trend to useminimally invasive approaches, even in cardiac surgery. Smaller incisions are clearly more cosmetically acceptable to patients. When using a minimally invasive approach, it is most important to maintain surgical quality without jeopardizing patients. A good operative visual field leads to good surgical results. In the parasternal approach, we use a retractor to harvest an internal thoracic artery in coronary artery bypass surgery. Retracting the sternum upward allows for a good surgical view and permits the use of an arch cannula rather than femoral cannulation. When reoperating for aortic valve repair, the j-sternotomy approach requires less adhesiolysis compared with the traditional full sternotomy. No special technique is necessary to perform aortic valve surgery using the j-sternotomy approach. However, meticulous attention must be paid to avoiding left ventricular air embolisms to prevent postoperative stroke or neurocognitive deficits, especially when utilizing a minimally invasive approach. Transesophageal echo is useful not only for monitoring cardiac function but also for monitoring the persence of air in the left ventricle and atrium. This paper compare as the degree of invasion of minimally invasive cardiac surgery and the traditional full sternotomy. No differences were found in the occurrence of systemic inflammatory response syndrome between patients undergoing minimally invasive cardiac surgery and the traditional technique. Therefore it is concluded that minimally invasive surgery for patients with aortic valve disease may become the standard approach in the near future.

Aortic Valve↗
PubMed1999

Anterior transsternal approach to the upper thoracic spine.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved towards less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection to partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of the upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform approach for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.

Aged↗
PubMedDate not supplied

[Trans-sternal approach to the cervicothoracic junction].

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved toward less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection and partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.

Aged↗
PubMed2000

[Minimally invasive direct coronary artery bypass grafting using subxiphoid approach].

We report twelve cases of minimally invasive coronary artery bypass grafting via small laparotomy using right gastroepiploic artery (RGEA) to the right coronary artery. Seven patients were operated on without partial sternotomy (N group), and lower partial sternotomy with Octopus 2 stabilization system was used in five of the cases (P group). Postoperative Doppler echographic imaging or angiographic study showed all RGEA grafts were functioning well in P group. However, graft occlusion was observed in two of the cases in N group. Inferior partial sternotomy combined with Octopus 2 stabilization system produce a clear surgical view, which avoids of both full-sternotomy and cardiopulmonary bypass. This method might be useful especially for reoperation.

Aged↗
PubMed2002

Sternum screw: analysis of a novel approach to the closure of the chest after surgery.

BACKGROUND: To show the benefits of using a novel approach to closure of the median sternotomy through a mechanical model and mechanical testing. Simple cannulated screws are placed on either side of the sternotomy. Conventional stainless steel wire is passed through the cannula of each screw and the sternotomy is closed in the usual manner. METHODS: Hertzian contact analysis was used to estimate the stress between the wire and the sternum. Mechanical testing was used to compare using wire on its own with a sternum screw plus wire. Ten samples of balsa wood (sternum substitute) had wire placed through a hole in them, while a further ten samples were fitted with a cannulated screw and had wire passed through the screw cannula. The wire was connected to a materials testing machine, which applied tension to the wire until the wire or screw cut through the wood. RESULTS: The analysis showed that the mean stress between the wire and the sternum decreases with increasing wire diameter. At low diameters of wire the stress in the sternum can be comparable to the failure stress of bone. Using a cannulated screw reduces the stresses in the sternum. The mechanical testing showed that the wire cut through the wood at a mean load of 104 N, whereas the sternum screw cut through the wood at a mean load of 209 N (p = 0.007, Mann-Whitney Test). CONCLUSIONS: Closing a median sternotomy with cannulated screws plus wire should reduce the occurrence of sternal dehiscence.

Biomechanical Phenomena↗
PubMed2002

Minimally invasive direct coronary artery bypass grafting (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB): two techniques for beating heart surgery.

OBJECTIVE: Coronary bypass surgery can be performed less invasively by avoiding cardiopulmonary bypass (CPB). We present our experiences with beating heart bypass surgery performed through a minithoracotomy or sternotomy. METHODS: From May 1997 to September 1999, 340 patients were included in a prospective study. Of these patients, 111 (group 1) underwent minimally invasive direct coronary artery bypass grafting (MIDCAB) through an antero-lateral minithoracotomy, and 229 (group 2) had off-pump coronary artery bypass grafting (OPCAB) through a full sternotomy. A pressure stabilizer was used for MIDCAB and a suction stabilizer for OPCAB surgery. Early postoperative angiography was performed on 48% of patients in group 1 and 45% of those in group 2. Statistical analysis was applied to compare the variables from both groups and a probability value of less than 0.05 was considered significant. RESULTS: In all MIDCAB grafts, revascularization was performed by a single left internal mammary artery (LIMA) graft to the left anterior descending coronary artery (LAD). This procedure was completed in 96.4% of patients without CPB. Conversion to sternotomy was necessary for one patient (0.9%). In the OPCAB group, an average of 1.7 grafts per patient were revascularized, of which 98 were single, 99 double, and 32 triple. Of the OPCAB group, 12% of patients were redo operations and 17% had severe comorbidities. Conversion to CPB was necessary for 10 patients (4.4%) because of hemodynamic instability. No cerebrovascular accident (CVA) was seen in any group. There were no hospital deaths in the MIDCAB group, but there were three deaths (1.3%) in the OPCAB group. Age, previous bypass surgery, and severe comorbidities did not influence early mortality. Early postoperative reoperation due to graft failure was necessary for three patients (2.7%) after MIDCAB and for three patients (1.3%) after OPCAB. Confirmed by angiography, the early postoperative total graft patency rate was 96.2% in the MIDCAB group and 96.6% in the OPCAB group; the perfect patency rate (no stenosis greater than 50%) was 92.4% and 93.1%, respectively. CONCLUSIONS: Coronary bypass surgery without the use of CPB is feasible and safe, and offers good early results. Nevertheless, MIDCAB grafting is a challenging technique and should only be performed in selected patients with favorable coronary anatomy. On the other hand, with the sternotomy approach, exposure of all vessels was well tolerated and made complete revascularization feasible. OPCAB can be performed safely even on high-risk patients.

Cardiopulmonary Bypass↗
PubMed2003

Experience in using three different minimally invasive approaches in cardiac operations.

BACKGROUND: In order to reach a clear understanding of minimally invasive approaches in cardiac operations, the authors review clinical experience in using three such approaches: inferior partial median sternotomy, right anterolateral minor thoracotomy, and the right parasternal approach. MATERIAL/METHODS: Sternotomy and the three different minimally invasive approaches were applied in and 2431 and 323 patients respectively. The approaches were selected according to the circumstances of the individual case. Both external and internal cardiac structures were observed during the operations. The length of the incision, the postoperative drainage, operative time, and cardiopulmonary bypass time were investigated. The postoperative complications occurring after minimally invasive approaches were observed. RESULTS: In inferior partial median sternotomy, all structures except for the ascending aorta could be exposed well. In right anterolateral minor thoracotomy, only the structures on the right side of the heart could be exposed, but the mitral valve could also be exposed well. The exposure of the right parasternal approach was similar to that of right anterolateral minor thoracotomy. There were statistically significant differences between sternotomy and the minimally invasive approaches in terms of incision length and postoperative drainage, but no difference in operative time and cardiopulmonary bypass time. The postoperative complications of MIAs included air embolism (n = 3), chest pain (n = 9), chest wall malacia (n = 1), rib fracture (n = 2), and sternum fracture (n = 2). The total incidence of complications in minimally invasive approaches was 5.3%. CONCLUSIONS: The minimally invasive approaches can have satisfactory clinical results if the approaches are correctly chosen and performed.

Adult↗
PubMed2004

Conversion of Endoscopic, Robotically Assisted Coronary Bypass: Incidence, Risk Factors, and Outcome.

Abstract Background: The clinical and financial consequences of conversion from endoscopic (robotically assisted) atraumatic coronary artery bypass (EndoACAB) to sternotomy (converted EndoACAB) have not been previously reported. This study sought to identify the incidence, causes, predictive factors, and adverse consequences of converted EndoACAB. Methods: Between June 1996 and June 2003, 509 patients underwent EndoACAB, and an additional 20 EndoACAB patients underwent converted EndoACAB. Data from the patients requiring conversion to sternotomy were retrospectively reviewed using multivariate regression and computer matched with data from a cohort of patients who underwent primary sternotomy (SternCAB). Results: The overall rate of conversion was 3.8% (20/509). Causes were: inability to expose the target vessel(s) (9), unsuitable internal mammary artery (7), intrathoracic bleeding (2), and hemodynamic instability (2). There were no statistical differences in mortality or major morbidity between converted EndoACAB patients versus the computer-matched SternCAB patients ( P = not significant). Hospital costs for the converted EndoACAB patients were higher than for the successful EndoACAB patients, but not higher than the computer-matched SternCAB patients. Conclusions: The incidence of conversion of EndoACAB patients to sternotomy was low and often occurred under elective circumstances. The clinical and economic consequences of conversion were minimal.

Journal Article↗