Cardiac Surgery: Beyond Conventional Sternotomy With Cardiopulmonary Bypass.

Minimally invasive cardiac surgery options, which originated with off-pump coronary artery bypass grafting and aortic valve procedures, continue to evolve in order to address complex conditions, including those requiring mitral and tricuspid valve repair. Although these procedures are primarily indicated for high-risk patient populations, favorable patient outcomes have resulted in recommendations being expanded to include intermediate-risk groups. This article increases nursing-related knowledge of minimally invasive cardiac procedures, providing an overview of current minimally invasive cardiac surgeries and their associated risks and benefits.

The effect of local anesthetic continuous wound infusion for the prevention of postoperative pneumonia after on-pump cardiac surgery with sternotomy: the STERNOCAT randomized clinical trial.

PURPOSE: Postoperative pain after cardiac surgery, exacerbated by cough and sternal mobilization, limits clearance of bronchopulmonary secretions and may predispose to postoperative pneumonia. In this study, we tested the ability of local anesthetic continuous wound infusion to prevent pneumonia after cardiac surgery with sternotomy and cardiopulmonary bypass (CPB) owing to better analgesia and bronchopulmonary drainage. METHODS: In this randomized, double-blind, placebo-controlled trial conducted in five academic centers, patients undergoing cardiac surgery with sternotomy and CPB were enrolled from February 2012 until November 2014, and were followed over 30 days. Patients were assigned to a 48-h infusion (10 ml h-1) of L-bupivacaine (12.5 mg h-1) or placebo (saline) via a pre-sternal multiperforated catheter. Anesthesia and analgesia protocols were standardized. The primary end point was the incidence of pneumonia during the study period, i.e., until hospital discharge or 30 days. We hypothesized a 30% reduction in the incidence of pneumonia. RESULTS: Among 1493 randomized patients, 1439 completed the trial. Pneumonia occurred in 36/746 patients (4.9%) in the L-bupivacaine group and in 42/739 patients (5.7%) in the placebo group (absolute risk difference taking into account center and baseline risk of postoperative pneumonia, - 1.3% [95% CI - 3.4; 0.8] P = 0.22). In the predefined subgroup of patients at high risk, L-bupivacaine decreased the incidence of pneumonia (absolute risk difference, - 5.6% [95% CI - 10.0; - 1.1], P = 0.01). CONCLUSIONS: After cardiac surgery with sternotomy, continuous wound infusion of L-bupivacaine failed to decrease the incidence of pneumonia. These findings do not support the use of local anesthetic continuous wound infusion in this indication. Further study should investigate its effect in high-risk patients. TRIAL REGISTRATION: EudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.

Minimally Invasive Access Aortic Arch Surgery.

OBJECTIVE: Median sternotomy is still the standard approach for aortic arch surgery. Minimally invasive techniques promise faster recovery with shorter hospital stay due to thoracic stability, reduced pain, and superior cosmetic results. However, safety is a concern in complex aortic surgery. The aim of our study was to demonstrate that aortic arch surgery via partial upper sternotomy is viable, safe, and equivalent to standard procedure both in terms of its safety and the risk of major adverse cardiac and cerebrovascular events. METHODS: We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in 3 patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, and acute kidney injury. RESULTS: Mean ± standard deviation age of patients was 69.3 ± 14.4 years, 57.1% were female, and mean ± standard deviation logistic EuroSCORE was 17.0 ± 7.2%. Surgery on the aortic arch comprised proximal arch in 9, hemiarch in 9, and total arch replacement plus frozen elephant trunk in 3 patients. Concomitant procedures included aortic root repair in 10, aortic root replacement in 2, and aortic valve replacement in 3 patients. We lost one patient because of septic shock, no stroke occurred, but a transient neurologic deficit in three and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, and one patient had acute kidney injury. CONCLUSIONS: Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of morbidity or mortality. Thus, in experienced hands, it is viable, safe, and therefore favorable and as a result should be offered to more patients.

Evaluation of augmented pulse pressure variation using the Valsalva manoeuvre as a predictor of fluid responsiveness under open-chest conditions: A prospective observational study.

BACKGROUND: Pulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial. OBJECTIVE: We evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy. DESIGN: A prospective, observational study. SETTING: Single-centre trial, study period from October 2014 to June 2015. PATIENTS: Forty-nine adult patients who underwent off-pump coronary arterial bypass grafting. INTERVENTION: After midline sternotomy, haemodynamic parameters were measured before and after volume expansion (6 ml kg of crystalloids). PPV was calculated both automatically (PPVauto) and manually (PPVmanual). For PPV augmentation, we performed Valsalva manoeuvres with manual holding of the rebreathing bag and constant airway pressure of 30 cmH2O for 10 s before fluid loading and calculated PPV during the Valsalva manoeuvre (PPVVM). MAIN OUTCOME MEASURES: The predictive ability of PPVVM for fluid responsiveness using receiver-operating characteristic curve analysis. Responders were identified when an increase in cardiac index of at least 12% occurred after fluid loading. RESULTS: Twenty-one patients were responders and 28 were nonresponders. PPVVM successfully predicted fluid responsiveness with an area under the curve (AUC) of 0.88 [95% confidence interval (95% CI) 0.75 to 0.95; sensitivity 91%, specificity 79%, P < 0.0001] and a threshold value of 55%. Baseline PPVauto and PPVmanual also predicted fluid responsiveness [AUC 0.75 (0.62 to 0.88); sensitivity 79%, specificity 75%; and 0.76 (0.61 to 0.87]; sensitivity 71%, specificity 71%, respectively). However, only PPVVM showed a significant AUC-difference from that of central venous pressure (P = 0.008) and correlated with the change of cardiac index induced by volume expansion (r = 0.6, P < 0.001). CONCLUSION: Augmented PPV using a Valsalva manoeuvre can be used as a clinically reliable predictor of fluid responsiveness under open-chest condition. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02457572.

Outcomes following the implementation of a quality control campaign to decrease sternal wound infections after coronary artery by-pass grafting.

BACKGROUND: Coronary artery by-pass grafting (CABG) remains the optimal strategy in achieving complete revascularization in patients with complex coronary artery disease. However, sternal wound infections (SWI), especially deep SWI are potentially severe complications to the surgery. At the department of cardiothoracic surgery in Uppsala University Hospital a gradual increase in all types of SWI occurred, which peaked in 2009. This prompted an in-depth revision of the whole surgical process. To monitor the frequency of post-operative infections all patients receive a questionnaire that enquires whether any treatment for wound infection has been carried out. METHODS: All patients operated with isolated CABG between start of 2006 and end of 2012 were included in the study. 1515 of 1642 patients answered and returned the questionnaire (92.3 %). The study period is divided into the time before the intervention program was implemented (2006-early 2010) and the time after the intervention (early 2010- end 2012). To assess whether potential differences in frequency of SWI were a consequence of change in the characteristics of the patient population rather than an effect of the intervention a retrospective assessment of medical records was performed, where multiple of the most known risk factors for developing SWI were studied. RESULTS: We noticed a clear decrease in the frequency of SWI after the intervention. This was not a consequence of a healthier population. CONCLUSIONS: Our results from implementing the intervention program are positive in that they reduce the number of SWI. As several changes in the perioperative care were introduced simultaneously we cannot deduce which is the most effective.

Cirugía mínimamente invasiva para el recambio valvular aórtico. Una técnica segura y útil más allá de lo estético / Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits

Introducción y objetivos. El objetivo es comparar resultados clínicos intrahospitalarios entre pacientes sometidos a recambio valvular aórtico aislado por abordaje mínimamente invasivo frente a esternotomía estándar. Métodos. Se incluyó a 615 pacientes sometidos a recambio valvular aórtico entre 2005 y 2012, 532 mediante abordaje estándar (grupo E) y 83 mediante miniesternotomía en «J» (grupo M). Resultados. No se encontraron diferencias significativas en cuanto a edad (69,27 ± 9,31 frente a 69,40 ± 10,24 años) y EuroSCORE logístico (6,27 ± 2,91 frente a 5,64 ± 2,17) entre los grupos E y M. Tampoco en la incidencia de diabetes mellitus, hipercolesterolemia, hipertensión arterial y enfermedad pulmonar obstructiva crónica o el tamaño de válvulas implantadas (grupo E frente a grupo M, 21,94 ± 2,04 y 21,79 ± 2,01 mm). Sí las hubo en los tiempos de circulación extracorpórea y de pinzamiento aórtico, mayores en el grupo E: 102,90 ± 41,68 frente a 81,37 ± 25,41 min (p < 0,001) y 77,31 ± 29,20 frente a 63,45 ± 17,71 min (p < 0,001) respectivamente. La mortalidad del grupo E fue del 4,88% (26). En el grupo M no hubo muertes (p < 0,05). No hubo diferencia en las complicaciones hemodinámicas, neurológicas, renales, infecciosas o de herida. Los días de estancia en unidad de cuidados intensivos y de estancia hospitalaria fueron más en el grupo E: 4,17 ± 5,23 frente a 3,22 ± 2,01 días (p = 0,045) y 9,58 ± 7,66 frente a 7,27 ± 3,83 días (p < 0,001). En el grupo E hubo más complicaciones respiratorias postoperatorias, 42 (8,0%) frente a 1 (1,2%) (p < 0,05). Conclusiones. El abordaje mínimamente invasivo presenta resultados al menos equiparables al estándar en cuanto a morbimortalidad y tiempos quirúrgicos, y en nuestra serie ha permitido disminuir significativamente la estancia hospitalaria. Dado que el estudio es retrospectivo, creemos que se debe confirmar estos hallazgos en estudios prospectivos aleatorizado(AU)

Introduction and objectives. The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. Methods. Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). Results. No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. Conclusions. In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results(AU)

Simple method for determining the need for sternotomy/manubriotomy with the anterior approach to the cervicothoracic junction.

OBJECTIVE: Frequently, the cervicothoracic junction can be reached through a simple anterior approach. In some cases, access to this region requires a much more aggressive surgical intervention, such as manubriotomy or sternotomy. Information regarding the need for such interventions is particularly useful to have preoperatively to guide surgical planning as well as discussions regarding surgical risks and expected morbidities. Whereas methods utilizing magnetic resonance imaging have been proposed for determining the lowest level that can be accessed through a simple low cervical approach, we describe a simple technique using sagittal computed tomographic imaging. Our technique does not require any complex geometry and has given us very consistent results. METHODS: Computed tomographic sagittal reconstruction of the cervical and upper thoracic spine that includes the entire sternum is obtained. The lowest accessible disc space is determined by a straight line passing through and parallel to the disc space that also passes above the manubrium (the intervertebral disc line). RESULTS: Sagittal computed tomographic reconstructions obtained from 50 adult patients were reviewed, and the lowest disc space accessible from an anterior low cervical approach was determined. The most common accessible level was T1-T2 (23 patients), followed by C7-T1 (13 patients), T2-T3 (10 patients), and C6-C7 (4 patients). A 35-year-old man with T2-T3 compression fractures with kyphotic deformity was treated with T2 and T3 vertebrectomies and T1-T4 fusion through an anterior approach. CONCLUSION: We propose a simple and consistent method for determining the need for manubriotomy or sternotomy for anterior approaches to the cervicothoracic junction.