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Concept: Median sternotomy

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OBJECTIVESSternal wound complications following median sternotomy remain a challenge in cardiac surgery. Changes in both patient profile and type of operations have been observed in recent years. Therefore, we analysed current wound healing complications after median sternotomy at our centre.METHODSAll adult patients undergoing a median sternotomy between January 2009 and April 2011 were included in this retrospective analysis. Transplants and assist devices implantations were omitted. We assessed outcome, prognostic factors and microbiological results of standardized wound swabs.RESULTSIn total, 1297 patients with an average age of 67.0 ± 12.7 years were analysed. Operation types included 598 solitary coronary artery bypass grafts (CABGs), 213 solitary valve procedures, 105 CABGs with aortic valve replacement and 116 solitary aortic operations or conduit implantations. Furthermore, 255 of the remaining 265 were combined or otherwise complex procedures. Superficial healing disorders occurred in 43 patients (3.3%), while 33 (2.5%) developed deep wound complications. Six patients with sternal wound complications (7.9%) died in-hospital. In 7 patients, no pathogen was identified and the wound appeared uninfected (21% of all deep complications or 0.05% of all patients). These healing disorders were considered deep dehiscences. Patients with insulin-dependent diabetes mellitus, BMI of >40 kg/m(2) and who underwent reoperation were prone to superficial infections. Risk factors for all deep sternal wound complications were insulin-dependent diabetes mellitus, COPD and reoperation. Moreover, multivariate analysis revealed ‘emergency’ as an independent prognostic factor for all sternal wound complications. Microbial swabs of the sternal wound were taken in 82 of the 1297 patients (6.6%). Pathogens of the normal skin flora represented the majority of pathogens in both superficial and deep wound complications. Eight patients with deep, but only 2 patients with superficial complications suffered from polymicrobial infections. All deep polymicrobial infections involved coagulase-negative Staphylococci.CONCLUSIONSWound complications following median sternotomy remain a challenge to cardiac surgery. Redo and emergency operations are the most important risk factors in this contemporary series. More efforts seem mandatory to decrease this arduous morbidity and the costs of prolonged treatment.

Concepts: Myocardial infarction, Insulin, Diabetes mellitus, Heart, Sternum, Wound, Coronary artery bypass surgery, Median sternotomy

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Background Postoperative acute pain can cause anxiety and decrease the quality of life in patients. Acute sternal bone pain after cardiac surgery can persist for long time.Objective The aim of this study is to explore the relationships between the degree of sternal misalignment and the degree of acute sternal pain after coronary artery bypass grafting surgery (CABG).Methods We retrospectively reviewed postoperative coronary computed tomographic (CT) angiography and medical records in 104 patients who received CABG between May 1, 2009 and January 31, 2011. CT scan was classified into five categories, and we compared the degree of misalignment and subjective pain via numerical rating scale (NRS) system.Results Positive correlation was noted between NRS and the degree of sternal misalignment (Pearson correlation coefficient 0.660, p = 0.000).Conclusion Postoperative sternal pain is related to the degree of misalignment of the sternal halves. It would be appropriate for surgeons to approximate the sternal halves accurately to decrease the postoperative sternal wound pain in the first place.

Concepts: Atherosclerosis, Heart, Spearman's rank correlation coefficient, Sternum, Correlation and dependence, Coronary artery bypass surgery, Pearson product-moment correlation coefficient, Median sternotomy

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Despite the large choice of wide-spectrum antibiotic therapy, deep sternal wound infection (DSWI) following cardiac surgery is a life-threatening complication worldwide. This study evaluated that the use of platelet-rich plasma (PRP) applied inside the sternotomy wound would reduce the effect of sternal wound infections, both superficial and deep. Between January 2007 and January 2012, 1093 consecutive patients underwent cardiac surgery through median sternotomy. Patients were divided into two groups. Group B, the study group, included those who received the PRP applied inside the sternotomy wound before closure. Group A, the control group, included patients who received a median sternotomy but without the application of PRP. Antibiotic prophylaxis remained unchanged all over the study and between the two groups. Occurrence of DSWI was significantly higher in group A than in group B [10 of 671 (1·5%) versus 1 of 422 (0·20%), P = 0·043]. Also, superficial sternal wound infections (SSWIs) were significantly higher in group A than in group B [19 of 671 (2·8%) versus 2 of 422 (0·5%), P = 0·006]. The use of PRP can significantly reduce the occurrence of DSWI and SSWI in cardiac surgery.

Concepts: Infectious disease, Bacteria, Infection, Sternum, Wound, Antiseptic, Median sternotomy

10

In people who have undergone cardiac surgery via median sternotomy, does modifying usual sternal precautions to make them less restrictive improve physical function, pain, kinesiophobia and health-related quality of life?

Concepts: Life, Heart, Randomized controlled trial, Sternum, Coronary artery bypass surgery, Median sternotomy, Sternal saw

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The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery.

Concepts: Randomized controlled trial, Avicenna, Sternum, Coronary artery bypass surgery, Upper limb, Limb, Limbs, Median sternotomy

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A median sternotomy could be difficult for a child with ectopia cordis and complex congenital cardiac anomalies. We report a patient with ectopia cordis, functionally single ventricle and bilateral superior vena cava, who underwent a staged Fontan procedure through a clamshell incision and the sternothoracotomy approach.

Concepts: Blood, Heart, Sternum, Inferior vena cava, Superior vena cava, Median sternotomy, Fontan procedure

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Sternotomy pain is a common complication after cardiac surgery. We present a 77-year-old patient with severe acute sternal pain after coronary artery bypass graft surgery who was successfully treated with a novel peripheral regional anesthetic technique, the pecto-intercostal fascial block. This interfascial plane block may represent an effective regional anesthetic component of a multimodal analgesic strategy for cardiac surgery patients who suffer from significant pain after a median sternotomy and are typically anticoagulated.

Concepts: Atherosclerosis, Medical terms, Heart, Sternum, Artery, Coronary circulation, Coronary artery bypass surgery, Median sternotomy

1

We present a case of surgical implantation of biventricular epicardial pacing leads and a defibrillating patch via lower half mini sternotomy. Although median sternotomy is routinely used for this purpose, lower half mini sternotomy could provide the surgeon with the same surgical field exposure and a faster post operative recovery.

Concepts: Surgery, Median sternotomy

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A 28-year-old male admitted with a stab wound under his left nipple, underwent emergency surgery because of confusion, a decreasing blood pressure and increasing tachycardia. A median sternotomy incision was made and after establishing cardiopulmonary bypass, a 7 cm wound in the left ventricle and a smaller wound in the left atrium were repaired. An injured segment of lung was resected and the left anterior descending and circumflex arteries were grafted after weaning from cardiopulmonary bypass was initially unsuccessful. Although the patient suffered a stroke, probably due to prehospital hypoperfusion, he eventually recovered without major sequelae. In addition to the case report we present a literature review of the last 15 years pertaining the management of penetrating cardiac injury.

Concepts: Blood, Heart, Vein, Injury, Ventricle, Coronary artery bypass surgery, Left ventricle, Median sternotomy

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Pseudoaneurysms arising from the left ventricular outflow tract are rarely reported. We report a 26-year-old man who was admitted with paroxysmal chest pain and dyspnoea on exertion. Computed tomography revealed the presence of a pseudoaneurysm (93 × 77 mm), and the communication was below the aortic annulus. Through median sternotomy, a huge pulsatile pseudoaneurysm was exposed, and an 8-mm-diameter communication of the pseudoaneurysm in the left ventricular outflow tract wall was visualized. The defect was successfully repaired, and the postoperative course was uneventful.

Concepts: Heart, Sternum, Tomographic reconstruction, Report, Hypertrophic cardiomyopathy, Aorta, Median sternotomy