Surgical considerations in patients undergoing repeat median sternotomy

Macmanus, Quentin; Je, Okies; Sj, Phillips; Starr, Adam M.

doi:10.1016/s0022-5223(19)41621-8

Cited by 73 publications

(21 citation statements)

References 4 publications

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“…3 Importantly, with a sternotomy approach, adequate operative exposure of the MV can be challenging secondary to dense adhesions -particularly in patients with previous aortic valve and/or aortic root surgery. [4][5][6] Most patients requiring reoperative mitral surgery are older and have multiple medical comorbidities that increase their overall perioperative risk. Recently, many of these higher-risk patients have been offered or treated with novel transcatheter mitral techniques, which may be associated with inferior efficacy and have unknown durability.…”

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confidence: 99%

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes

Losenno

Jones

Valdis

et al. 2016

cjs

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Background: Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. Methods:We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. Results:We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. Conclusion:A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant differences in perioperative complications require assessment in randomized clinical trials.Contexte : Les réopérations de la valve mitrale (VM) sont associées à une morbidité et à une mortalité importantes. Cependant, il semblerait que les techniques chirurgicales endoscopiques à effraction minimale préservent les avantages des opérations traditionnelles de la VM tout en réduisant potentiellement les risques périopératoires et la durée d'hospitalisation.Méthodes : Nous avons comparé les résultats de patients consécutifs ayant subi une réopération de la VM entre 2000 et 2014 selon une approche endoscopique à effraction minimale (groupe MINI) à ceux de patients ayant subi une sternotomie classique (groupe STERN). Le résultat primaire à l'étude était la mortalité intrahospitalière ou dans les 30 premiers jours, et les résultats secondaires, la transfusion de produits sanguins, la durée du séjour à l'hôpital et à l'unité des soins intensifs (USI), ainsi que les complications postopératoires.Résultats : Nous avons retenu 132 pa...

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confidence: 99%

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes

Losenno

Jones

Valdis

et al. 2016

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“…The technique used in the current series is similar to what has been described before by other groups. 4–10 A number of advantages are described: it avoids the need for a repeat sternotomy and its associated risk of injury to cardiac structures, potential catastrophic cardiac injury and sternal wound infection 11 ; by limiting the degree of adhesiolysis required, through entry via a preserved right pleural space and avoiding the need for dissection around the aorta for cross-clamping, there is a potential reduction in the operative and CPB times as well as the risk of perioperative bleeding. 12 If the right pleura has not previously been entered, there are rarely any significant pleuropericardial adhesions and access to the mitral valve requires only minimal adhesiolysis.…”

Section: Discussionmentioning

confidence: 99%

Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes

Rahnavardi

Nadal

et al. 2018

Open Heart

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ObjectiveReoperative mitral valve surgery is increasingly required and can be associated with significant morbidity and mortality. The beating heart minimally invasive mitral valve surgery has a proposed benefit in avoiding the risks of repeat sternotomy, with reducing the need for adhesiolysis and cardioplegia reperfusion injury. We describe our experience with such a technique in patients with previous sternotomy.MethodsA retrospective study was performed and all patients undergoing surgery of mitral valve through a right limited thoracotomy without application of an aortic cross-clamp (beating heart) as a redo cardiac surgery between January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are presented.ResultsSix patients (24%) had two previous sternotomies and one (4%) had three previous sternotomies. Mitral valve repair was performed in 11 patients (44%). No patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was required in seven patients (28%). Ventilation time was less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after surgery. Postoperative course was complicated with cerebrovascular accident in two patients (8%). In-hospital mortality was 4% (n=1). There was no 30-day mortality after discharge.ConclusionsReoperative mitral valve surgery can be safely performed through a limited right thoracotomy approach on a beating heart while on full cardiopulmonary bypass. The technique can be associated with potentially shorter operation, shorter cardiopulmonary bypass and a less complicated recovery.

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“…These injuries often result in severe hemorrhage with significant morbidity and mortality. 11,12 Dobell and Jain 13 report that 88% of hemorrhage occurs during the reoperation procedures due to adhesion to the retrosternum. Likewise, retrosternal adhesion of the gastric conduit and its gastroepiploic vessels pulled up through the retrosternal route can be predicted.…”

Section: Discussionmentioning

confidence: 99%

“…At the time of cardiac reoperation, if it is implemented, the risks caused by retrosternal adhesions include injuries to the right ventricle, aorta, right atrium, and an aortocoronary bypass graft. These injuries often result in severe hemorrhage with significant morbidity and mortality 11,12 . Dobell and Jain 13 report that 88% of hemorrhage occurs during the reoperation procedures due to adhesion to the retrosternum.…”

Section: Discussionmentioning

confidence: 99%

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

Kinoshita

Udagawa

Tsutsumi

et al. 2009

Diseases of the Esophagus

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Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re-anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re-reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull-up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re-anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.

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Surgical considerations in patients undergoing repeat median sternotomy

Cited by 73 publications

References 4 publications

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes

Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

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