Access to the Heart – Evolution of surgical techniques (original) (raw)

Closed heart surgery: Back to the future

The Journal of Thoracic and Cardiovascular Surgery, 2006

I n 1912, a famous thoracic surgeon, Theodore Tuffier, was presented a young patient with disabling symptoms caused by aortic stenosis. He planned to treat the patient by using inflow occlusion cutting the aortic valve leaflets with a knife. About to snare the cava, he noted that the aortic wall was flaccid, so he used his finger to invaginate the anterior aortic wall through the valve orifice. Immediately the palpable systolic vibration of the aortic wall was diminished. When examined 12 years later, the patient was alive and well. 1 Tuffier had performed the first successful closed heart surgery. Aortic stenosis of the senile calcific variety is today the most common valvular disease in the Western World, occurring in 2.9% of adults aged more than 65 years. 2-4 Its hemodynamic precursors include congenital bicuspid malformation and acquired insults such as rheumatic heart disease, endocarditis, myxomatous proliferation, and trauma, which progress to a combination of stenosis and regurgitation. 2 Once symptoms, in particular left ventricular dysfunction, become manifest, the prognosis is poor and medical therapy is not likely to modify the course of the disease. 4 Balloon valvuloplasty has been attempted but with only transient modest improvement and is reserved for palliation only. 5 Open surgery therefore remains the treatment of choice for symptomatic aortic stenosis, and open aortic valve replacement is exceedingly effective in eliminating symptoms and improving prognosis. 6 Open surgery, however, necessarily entails the risks and morbidity associated with cardiopulmonary bypass, clamping of the aorta, myocardial preservation, and median sternotomy, with operative mortalities as high as 20% reported in elderly patients and those with concomitant left ventricular dysfunction. 7,8 Because senile aortic stenosis is a disease of the elderly, comorbidities are a frequent concern and render some patients inoperable. Ironically, nearly 100 years after Tuffier's pioneering work, closed procedures are again being reconsidered by cardiac surgeons as an option for aortic stenosis. 9 Catheter-based aortic valve implantation in animal models was introduced in 1992, 10,11 and 10 years later Cribier and colleagues 12 described the first successful human aortic valve implantation using the venous antegrade transeptal approach. More recently at our institution, Webb and colleagues 13 reported on patients treated by retrograde arterial implantation of prosthetic aortic valves. Ye and colleagues 9 reported on the deployment of an aortic valve prosthesis for severe aortic stenosis through the apex of the left ventricle in a 75-year-old patient (a closed heart surgery procedure). This report of successful implantation of an aortic valve prosthesis through the apex of the left ventricle without sternotomy or the use of cardiopulmonary bypass in a human 9 provides a glimpse of an indispensable future role for cardiac surgery with this modality. At present this procedure is offered to patients deemed to be nonsurgical candidates, but we can fully expect the indications in the future to be expanded to high-risk surgical candidates and likely even further, depending on the proven clinical durability of the device. Although clinical experience is obviously limited, in vitro valve durability has been repeatedly documented to 200 million cycles or more than 5 years of life. Before the development of cardiopulmonary bypass by Gibbon in the 1950s, 14 cardiac surgeons were ingenious in developing instruments for closed heart surgery. Examples include the valvulotome and dilating forceps for pulmonary valvulotomy and the infundibular punch for right ventricular outflow tract obstruction. 1,15 Indeed, now a lost art, the past era of cardiac surgeons were very comfortable with the

Median sternotomy - gold standard incision for cardiac surgeons

Journal of Clinical and Investigative Surgery, 2016

Sternotomy is the gold standard incision for cardiac surgeons but it is also used in thoracic surgery especially for mediastinal, tracheal and main stem bronchus surgery. The surgical technique is well established and identification of the correct anatomic landmarks, midline tissue preparation, osteotomy and bleeding control are important steps of the procedure. Correct sternal closure is vital for avoiding short- and long-term morbidity and mortality. The two sternal halves have to be well approximated to facilitate healing of the bone and to avoid instability, which is a risk factor for wound infection. New suture materials and techniques would be expected to be developed to further improve the patients evolution, in respect to both immediate postoperative period and long-term morbidity and mortality.

Less invasive cardiac operations through a median sternotomy: 100 consecutive cases

The Annals of Thoracic Surgery, 1998

Background. In the beginning of 1997, we developed a routine approach to intracardiac operations through a less invasive median sternotomy. A limited (6 to 9 cm) median skin incision followed by a subcomplete (manubrium and body) median sternotomy makes opening and closing of the chest easier; conventional central cardiopulmonary bypass is instituted, and no modifications to the surgical techniques are necessary.

Abstract Journal Cardiothoracic Surgery

ANZ Journal of Surgery, 2017

The midline sternotomy wound typically performed for cardiac surgery can become complicated by dehiscence, infection, sterile non-union. This can be catastrophic for the patient and requires prompt reconstructive intervention. Various techniques of sternotomy revision exist in the literature. The purpose of this retrospective case series is to report the senior author's preferred technique for this defect, the bilateral pectoralis major myocutaneous flap advancement, with regard to patient demographics, indications for reconstruction, and surgical outcomes. Methodology: Local ethics approval was attained for the study. A chart review was conducted of the primary surgeon's logbook and matched with operative database at Prince Charles Hospital in Brisbane Australia between 1998 and 2016. Data was collected pertaining to patient demographics, comorbidities, index cardiac surgery, ICU admission, reconstructive surgery and outpatient follow up. Results: Over 300 cases were included in the study in the 18-year period. Most cases were referred for acute deep sternal wound infection after CABG procedure. Healing rates were in excess of 95% within the 12 month follow up period. Cases of sterile non-union continued to be un-united at the 12-month mark. Conclusions: This represents the largest single study looking at complicated sternal wound reconstruction in the literature. The bilateral pectoralis major myocutaneous flap reconstruction offers a robust vascularised reconstruction of the midline defect through the same single incision used for the original cardiac surgery.

Delayed Sternal Closure in Cardiac Surgery

Journal of Clinical & Experimental Cardiology, 2015

Background: Delayed sternal closure (DSC) has a reported incidence of 1.2%-4.2% in the adult cardiac surgical literature for indications including hemodynamic instability, marked myocardial edema, respiratory compromise, intractable bleeding, placement of assist devices, and persistent arrhythmias. The purpose of this study was to evaluate the incidence, survival, and morbidity of open chest management (OCM) patients who subsequently required DSC. Methods: All data were collected from the Robert Wood Johnson University Hospital Cardiac Surgery Database. A total of 1261 patients who underwent cardiac surgery from January 2012 through June 2013 were analysed, evaluating postoperative morbidity and mortality, along with inciting conditions for the utilization of DSC. Chi-square and frequency analysis were performed using SAS 9.3 software (SAS Institute, NC). Results: A total of 41/1261 (3.25%) cases resulted in DSC. Of the cases requiring DSC, 33/41 (80.5%) were men and 8/41 (19.5%) were women. Analysis revealed 11/41 (26.8%) of cases requiring delayed sternal closure were orthotopic heart transplants, 9/41(21.9%) insertion of ventricular (uni-or bi-ventricular) assist devices (VAD), 8/41 (19.5%) operations were coronary artery bypass graft (CABG), 4/41 (9.76%) were type A aortic dissection graft repairs, 2/41 (4.88%) were mitral valve repairs (MVR), 2/41 (4.88%) were aortic valve repair (AVR) combined with CABG, 2/41 (4.88%) were MVR with CABG, and 3/41 (7.32%) were other cardiac procedures. There were no incidences of superficial sternal infection or mediastinitis in the DSC cohort, while infection occurred in 3/1220 (0.25%) patients after conventional closure. Analysis of postoperative comorbidities revealed acceptable rates of postoperative stroke [2/41 (4.88%)], atrial fibrillation [6/41 (14.6%)], and renal failure [16/41 (39.0%)]. Overall mortality was 14/41 (34.2%). Reasons for planned DSC included bleeding 7/41 (17.1%), hemodynamic instability 11/41 (26.8%), elevated pulmonary artery (PA) pressures in 4/41 (9.76%), and coagulopathy in 19/41 (46.3%), while graft occlusion and valve dysfunction were not factors leading to the implementation of DSC. Conclusion: DSC is a technique that can be readily used in patients who require OCM for various reasons following cardiac surgery. DSC does not appear to increase the risk of infectious complications. Although postoperative complications such as stroke, atrial fibrillation, and renal failure, along with an acceptable mortality rate, is reflective of the patients' morbid condition requiring OCM, DSC can be carried out with a relatively low incidence of sternal complications after cardiac surgery.

Full sternotomy with minimal skin incision for congenital heart surgery

Cardiovascular Surgery, 2002

The purpose of this paper is to analyze the feasibility of the full sternotomy with minimal skin incision and its related complications and risks. Methods: A total of 405 patients with simple congenital heart disease underwent open heart surgery exclusively under full sternotomy with minimal skin incision. We reviewed the available medical records of the patients retrospectively. Bypass time, aorta cross clamp time, and period of hospital stay were compared with the control group (223 patients with standard long skin incision). Results: Full sternotomy with minimal skin incision provided adequate surgical views and successful repair was done in all patients. There was no mortality. One patient had chylopericardium after the operation and another patient had a postoperative bleeding at the sternum. Minimal skin incision took the similar aorta cross-clamp time and total cardiopulmonary bypass time compared with full skin incision in atrial septal defect patients. Among the ventricular septal defect patients, minimal skin incision took a little longer aorta cross-clamp time (10%), but similar total cardiopulmonary bypass time compared with full skin incision. Conclusion: Minimal skin incision with full sternotomy provides improved cosmetic results. There was no increased mortality and morbidity using minimal access. It can be applied to more complex congenital heart disease contrast to other minimal invasive techniques for atrial septal defect.

Full-Spectrum Cardiac Surgery Through a Minimal Incision: Mini-Sternotomy (Lower Half) Technique

The Annals of Thoracic Surgery, 1998

A technique is described in which most, if not all, cardiac operations may be performed through a standard small incision. A midline, lower half sternotomy is used. This provides traditional exposure of the heart and allows the surgeon to directly visualize the operating field and use familiar instruments. The complete spectrum of coronary revascularization and cardiac valve operations has been performed through this less-invasive incision.

Minimally invasive and maximally safe approach to cardiac surgery

Indian Journal of Thoracic and Cardiovascular Surgery, 2000

Background Minimally invasive approaches in cardiac surgery have been introduced in an attempt to limit post operative pain, allow prompt recovery, and reduce the cosmetic impact of the scar. We describe a surgical technique of limited skin incision with complete median sternotomy. Patients & Methods A comparative study was performed using two groups of 35 patients each in which a minimally invasive incision (Group I) was compared to a routine incision (Group II). Surgical procedures included atrial septal defect closure, mitral, aortic and tricuspid valve surgery. Results Incision length ranged from 6.9cm to 7.5cm (mean 7.1±0.2cm) in Group I and from 16.5cm to 21cm (mean 19.4 ±1.2cm) in Group II (Group I vs Group II, p<0.01). The operating time, cardiopulmonary bypass time, aortic cross clamp time were not significantly different in both the groups. Similarly, post-operative drainage was also not significantly different. The mean hospital stay of patients in Group I was 5.7±1.0 days operative mortality or morbidity. Conclusion This technique provides full, safe and easy access to all cardiac structures with acceptable cosmetic results. No special instruments are required.