Is resternotomy in cardiac surgery still a problem?

Surgical Considerations in Adult Congenital Heart Disease Heart Failure

Surgical intervention is often used in the management of heart failure in patients with adult congenital heart disease. This review addresses anatomic variations and complications due to prior surgical interventions, including sternal reentry, collateral vessels, and the neo-aortic root after the Damus-Kaye-Stansel procedure. Surgical considerations for systemic atrioventricular valvular surgery, Fontan revision, and advanced heart failure therapies including ventricular assist devices, heart transplant, and combined heart-liver transplant are discussed, with a focus on unique patient populations including those with systemic right ventricles and those with Fontan circulation.

The impact of reoperative surgery on aortic root replacement in the United States

OBJECTIVE

Reoperative sternotomy is associated with poor outcomes after cardiac surgery. We aimed to investigate the impact of reoperative sternotomy on the outcomes after aortic root replacement.

METHODS

All patients who underwent aortic root replacement from January 2011 to June 2020 were identified using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. We compared outcomes between patients who underwent first-time aortic root replacement with those with a history of sternotomy undergoing reoperative sternotomy aortic root replacement using propensity score matching. Subgroup analysis was performed among the reoperative sternotomy aortic root replacement group.

RESULTS

A total of 56,447 patients underwent aortic root replacement. Among them, 14,935 (26.5%) underwent reoperative sternotomy aortic root replacement. The annual incidence of reoperative sternotomy aortic root replacement increased from 542 in 2011 to 2300 in 2019. Aneurysm and dissection were more frequently observed in the first-time aortic root replacement group, whereas infective endocarditis was more common in the reoperative sternotomy aortic root replacement group. Propensity score matching yielded 9568 pairs in each group. Cardiopulmonary bypass time was longer in the reoperative sternotomy aortic root replacement group (215 vs 179 minutes, standardized mean difference = 0.43). Operative mortality was higher in the reoperative sternotomy aortic root replacement group (10.8% vs 6.2%, standardized mean difference = 0.17). In the subgroup analysis, logistic regression demonstrated that individual patient repetition of (second or more resternotomy) surgery and annual institutional volume of aortic root replacement were independently associated with operative mortality.

CONCLUSIONS

The incidence of reoperative sternotomy aortic root replacement might have increased over time. Reoperative sternotomy is a significant risk factor for morbidity and mortality in aortic root replacement. Referral to high-volume aortic centers should be considered in patients undergoing reoperative sternotomy aortic root replacement.

Long-term predictors of morbidity and mortality in patients following LVAD replacement

BACKGROUND

As heart transplant guidelines evolve, the clinical indication for 73% of durable left ventricular assist device (LVAD) implants is now destination therapy. Although completely magnetically levitated LVAD devices have demonstrated improved durability relative to previous models, LVAD replacement procedures are still required for a variety of indications. Thus, the population of patients with a replaced LVAD is growing. There is a paucity of data regarding the outcomes and risk factors for those patients receiving first-time LVAD replacements.

METHODS

The study cohort consisted of all consecutive patients between 2006 and 2020 that received a first-time LVAD replacement at a single institution. Preoperative clinical and laboratory variables were collected retrospectively. The primary endpoint was death or need for an additional LVAD replacement. Data were subjected to Kaplan-Meier, univariate, and multivariate Cox hazard ratio analyses.

RESULTS

In total, 152 patients were included in the study, of which 101 experienced the primary endpoint. On multivariate analysis, patients receiving HeartMate 3 (HM3) LVADs as the replacement device showed superior outcomes (HR 0.15, 95% CI 0.065-0.35, p < 0.0001). Independent risk factors for death or need for additional replacement included preoperative extracorporeal membrane oxygenation (ECMO) (HR 4.44, 95% CI 1.87-14.45, and p = 0.00042), increased number of sternotomies (HR 5.20, 95% CI 1.87-14.45, and p = 0.0016), and preoperative mechanical ventilation (HR 1.98, 95% CI 1.01-3.86, and p = 0.045).

CONCLUSIONS

Replacement with HM3 showed superior outcomes compared to all other pump types when controlling for both initial pump type and other independent predictors of death or LVAD replacement. Preoperative ECMO, mechanical ventilation, and multiple sternotomies also increased the odds for death or the need for subsequent replacement.

Sutureless Biological Aortic Valve Replacement (Su-AVR) in Redo operations: a retrospective real-world experience report of clinical and echocardiographic outcomes

OBJECTIVE

This retrospective study aimed to compare the outcomes of sutureless aortic valve replacement (su-AVR) and conventional bioprosthetic sutured AVR (cAVR) in high-risk patients undergoing redo surgery.

METHODS

A total of 79 patients who underwent redo AVR between 2014 and 2021 were included in the study. Of these, 27 patients underwent su-AVR and 52 underwent cAVR. Patient characteristics and clinical outcomes were analysed using multivariate regression and Kaplan Meier survival test.

RESULTS

The groups were similar in terms of age, gender, left ventricular function, and number of previous sternotomies. In cases of isolated AVR, su-AVR had significantly lower cross clamp times than cAVR (71 vs. 86 min, p = 0.03). Postoperatively, 4 cAVR patients required pacemaker compared to zero patients in the su-AVR group. There were no significant differences between the two groups in terms of postoperative complications, intrahospital stay (median 9 days, IQR 7-20), or in-hospital mortality (1 su-AVR; 2 cAVR). The long-term survival rate was similar between the su-AVR (90%) and cAVR (92%) groups (log rank p = 0.8). The transvalvular gradients at follow-up were not affected by the type of valve used, regardless of the valve size (coef 2.68, 95%CI -3.14-8.50, p = 0.36).

CONCLUSION

The study suggests that su-AVR is a feasible and safe alternative to cAVR in high-risk patients undergoing redo surgery. The use of su-AVR offers comparable outcomes to cAVR, with reduced cross clamp times and a lower incidence of postoperative pacemaker requirement in isolated AVR cases. The results of this study contribute to the growing body of evidence supporting the use of su-AVR in high-risk patients, highlighting its feasibility and safety in redo surgeries.

Mitral valve surgery via repeat median sternotomy versus right mini-thoracotomy: A systematic review and meta-analysis of clinical outcomes

BACKGROUND

Redo mitral valve surgeries have high mortality and morbidity and can be physically demanding for patients. Median sternotomy remains the gold standard for most cardiac surgeries. To tackle certain risks with a re-sternotomy, alternative procedures such as the right anterolateral minithoracotomy have been explored. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery.

METHODS

A systematic, electronic search was performed according to Preferred Reporting items for Systematic Reviews and Meta-analysis guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via a MS approach.

RESULTS

Twelve studies were identified, enrolling 4514 patients. Length of hospital stay(MD = -3.71, 95% confidence interval [CI] [-4.92, -2.49]), 30-day mortality(odds ratio [OR] = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR = 0.38, 95% CI [0.22, 0.65]) were statistically significant in favor of the MT approach. Infection rates(OR = 0.56, 95% CI[0.25, 1.21]) and length of intensive care unit (ICU) stay (MD = -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD = -2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD = -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR = 1.03, 95% CI[0.55, 1.92]).

CONCLUSION

Right MT is a safe alternative to the traditional re-sternotomy for patients who have had previous cardiac surgery. The approach offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis. This review calls for robust trials in the field to further strengthen the evidence.

Heart transplantation using manubrium-sparing sternotomy for sternal re-entry

We report a technique of heart transplantation performed by manubrium-sparing sternotomy for challenging re-entry after minimally invasive left ventricular assist device insertion. A T-shaped, manubrium-sparing sternotomy was performed using an oscillating saw up to the first intercostal space. After cardiopulmonary bypass was established via the right axillary artery and percutaneous venous cannulation of the right jugular and femoral vein, the outflow graft was ligated and divided via a left thoracotomy. All anastomoses were performed with a standard technique with an excellent exposure and outcome.

Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts

OBJECTIVE

The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts.

METHODS

Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival.

RESULTS

Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population.

CONCLUSIONS

Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure

OBJECTIVES

A minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation.

METHODS

From 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy.

RESULTS

The mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients.

CONCLUSIONS

A minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.

4-Arm PEG-Functionalized Decellularized Pericardium for Effective Prevention of Postoperative Adhesion in Cardiac Surgery

Postoperative adhesions are a very common and serious complication in cardiac surgery, and the development of an effective anti-adhesion membrane showing resistance to the physical stimulus generated by the pulsation of the heart is desirable. In this study, an anti-adhesion material was developed through amine coupling between decellularized bovine pericardia (dBPCs) and 4-arm poly(ethylene glycol) succinimidyl glutarate (4-arm PEG-NHS) for the postoperative care of cardiac surgical patients. The efficacy of the 4-arm PEG-functionalized dBPCs in the prevention of adhesions after cardiac surgery was investigated in a rabbit heart adhesion model. The dBPCs meet the requirements for biocompatibility, flexibility, and sufficient suturable strength, and the 4-arm PEG moieties provide an anti-adhesion effect by the high excluded volume interactions of the PEG chains with proteins. The 4-arm PEG-functionalized dBPCs had a significantly greater anti-adhesion effect than the other materials tested and showed re-establishment of the mesothelial monolayer. These results suggested that the 4-arm PEG-functionalized dBPCs are a favorable material for an anti-adhesion membrane.

Immediate results of minimally invasive redo off-pump coronary artery bypass grafting

Coronary heart disease (CHD) ranks first among the causes of death from cardiac events. Patients who have previously undergone surgical treatment – coronary artery bypass grafting (CABG) – are not immune from the return of angina due to the progression of atherosclerosis in the native coronary arteries or degenerative changes in the shunts. Therefore, the issue of redo surgery in this group of patients is debatable.

The aim of the research is to show that the use of alternative sternotomy approaches and the rejection of artificial blood circulation (ABC) are considered as possible measures to improve the results of redo CABGs.

Materials and methods. In the Cardiac Surgery Unit No. 1 of the Irkutsk Regional Clinical Hospital from 2003 to 2020, 6773 off-pump CABG surgeries were performed. Of these, 6338  (93.6  %) surgeries were performed using median sternotomy and  435  (6.4  %) surgeries were performed using minitoracotomy or subxyphoid access. Of the 6338 CABG surgeries performed using sternotomy, 58 (0.9 %) were performed repeatedly. All redo surgeries during the period under review were performed by minithoracotomy or subxyphoid access. The indication for redo surgery was the return of angina of III or IV functional class, which did not respond to optimal drug therapy. When performing 54 redo surgeries, the access was leftsided mini-thoracotomy. In 3 patients, CABG was performed by subxyphoid access and in 1 patient – from right-sided mini-thoracotomy.

Results. 58 redo CABG surgeries were performed. There was no damage to the access of the heart or functioning shunts. Complications were noted in 5 (8.6 %) patients. In 1 case, a second operation was required due to bleeding from the intercostal artery. In other cases, there were rhythm disturbances, or the need for inotropic support.

Conclusion. Performing redo off-pump CABG surgeries using mini-accesses reduces the risk of damage to the heart and functioning shunts, eliminates manipulations on the ascending aorta, and avoids difficulties with cardioplegic protection of the myocardium with a functioning mammarocoronary graft. 

Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma

Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.

Repeat aortic valve surgery: contemporary outcomes and risk stratification

OBJECTIVES

Redo aortic valve surgery (rAVS) is performed with increasing frequency, but operative mortality is usually higher compared to that associated with primary aortic valve surgery. We analysed our patients who had rAVS to determine the current outcomes of rAVS as a surgical benchmark in view of the growing interest in transcatheter valve techniques.

METHODS

We retrospectively reviewed 148 consecutive patients [median age 67.7 years (interquartile range 54.9-77.6); 68.2% men] who underwent rAVS following aortic valve replacement (81.6%), aortic root replacement (15%) or aortic valve repair (3.4%) between 2000 and 2018.

RESULTS

Indications for rAVS were structural valve dysfunction (42.7%), endocarditis (37.8%), non-structural valve dysfunction (17.7%) and aortic aneurysm (2.1%). Valve replacement was performed in 69.7%, and 34 new root procedures were necessary in 23%. Early mortality was 9.5% (n = 14). Female gender [odds ratio (OR) 6.16], coronary disease (OR 4.26) and lower creatinine clearance (OR 0.95) were independent predictors of early mortality. Follow-up was 98.6% complete [median 5.9 (interquartile range 1.7-10.9) years]. Survival was 74.1 ± 3.7%, 57.9 ± 5.1% and 43.8 ± 6.1% at 5, 10 and 14 years, respectively. Cox regression analysis revealed female gender [hazard ratio (HR) 1.73], diabetes (HR 1.73), coronary disease (HR 1.62) and peripheral vascular disease (HR 1.98) as independent determinants of late survival.

CONCLUSIONS

Despite many urgent situations and advanced New York Heart Association functional class at presentation, rAVS could be performed with acceptable early and late outcomes. Risk factors for survival were female gender, coronary disease and urgency. In this all-comers patient cohort needing rAVS, only a minority would eventually qualify for transcatheter valve-in-valve procedures.

Anesthetic management of a patient with severe aortic regurgitation undergoing reoperation for ascending aorta false aneurysm using hypothermia: prevention of ventricular fibrillation by nifekalant

BACKGROUND

To prevent cardiac collapse and to protect cerebral function, hypothermic cardiopulmonary bypass is established before resternotomy. However, ventricular fibrillation under hypothermia facilitates left ventricular distension, which causes irreversible myocardial damage when the patient has aortic regurgitation. We report a case of successful management in preventing ventricular fibrillation under hypothermia by using nifekalant.

CASE PRESENTATION

A 56-year-old male, who had been performed a David operation, was scheduled for a Bentall operation for a pseudo aortic aneurysm with severe aortic regurgitation. After inducing anesthesia, we administered intravenous nifekalant and a vent tube was inserted into the left ventricle under one-lung ventilation. Extracorporeal circulation was established and resternotomy started after cooling to 27 °C. Although severe bradycardia and QT prolongation were observed, ventricular fibrillation did not occur until aortic cross-clamping.

CONCLUSION

Combining maintaining cerebral perfusion and avoiding left ventricle distension during hypothermia was successfully managed with nifekalant in our redo cardiac patient with aortic regurgitation.

Minimally invasive (mini-thoracotomy) versus median sternotomy in redo mitral valve surgery: A meta-analysis of observational studies

OBJECTIVE

Redo mitral valve surgery has traditionally been performed via a median sternotomy. It is often challenging and is associated with increased perioperative mortality. Advances in cardiac surgical techniques over the last two decades have led to an increase in the use of a minimally invasive approach via a right anterolateral mini-thoracotomy as opposed to a repeat median sternotomy. However, despite these advances, there is no general consensus on the best form of entry, and as of yet, there are no randomized controlled trials. We performed a meta-analysis of observational studies to aid in determining the best approach for redo mitral valve surgery.

METHOD

The MEDLINE and EMBASE databases were conducted up until 1 June 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random effects modelling and the I²-test for heterogeneity. Seven retrospective observational studies were included, enrolling a total of 1070 patients.

RESULTS

There were a total of 1070 patients. Of these 364 had non-sternotomy approach compared with 707 patients who had median sternotomy. Further subgroup analysis revealed that 327 of the 364 patients had a mini-thoracotomy approach while the remaining 37 patients had a full thoracotomy approach. In-hospital mortality and length of stay were less in non-sternotomy group compared to median sternotomy group. There were no differences in stroke, CPB time and wound infections between the two groups.

CONCLUSION

Redo mitral valve surgery can be performed safely with satisfactory outcomes via a mini-thoracotomy approach. This meta-analysis shows comparable results with reduced in-hospital mortality and hospital length of stay with a mini-thoracotomy approach.

Preoperative Arterial and Venous Cannulation in Redo Cardiac Surgery: From the Safety and Cost-effectiveness Points of View

OBJECTIVE

To investigate the safety and cost-effectiveness of preoperative cannulation and conventional approach techniques.

METHODS

Sixty-one patients who underwent redo open cardiac procedures between September 2015 and November 2018 were divided into two groups - Group A (n: 30), patients who underwent conventional cannulation after sternotomy, and Group B (n: 31), those who underwent cannulation before sternotomy. Patients were evaluated retrospectively for general complication rates and total hospital costs.

RESULTS

Mortality occurred in four patients from Group A and in one patient from Group B. Four patients required extracorporeal membrane oxygenation (ECMO) in Group A, whereas two required ECMO in Group B. Duration of total operation, cardiopulmonary bypass, and cross-clamp times were longer in the conventional surgery group than in the pre-sternotomy cannulation group (420.29±188.84 vs. 314.77±187.38, P=0.036; 171.87±85.59 vs. 141.7±82.47, P=0.089; and 102.94±70.67 vs. 60.97±52.81, P=0.009; respectively). Total blood and blood product usage were higher in Group A than in Group B. Postoperative intensive care unit stay was 62.77±145.3 hours vs. 25.13±73.11 hours, ventilation time was 5.16±5.09 hours vs. 3.03±2.78 hours, duration of ward stay was 5.23±2.52 days vs. 5.57±2.16 days, and duration of hospital stay was 9.58±5.85 days vs. 9.8±5.31 days in conventional sternotomy and pre-sternotomy cannulation groups, respectively. Total hospital costs were calculated 35863.52±20803.99 Turkish Liras (TL) in Group A and 25744.74±16472.03 TL in Group B (P=0,042).

CONCLUSION

Venous and arterial cannulations before sternotomy decreased myocardial injury and complication rates, blood and blood product usage, hospital stay, and, consequently, hospital costs in our modest cohort.

Preoperative Computed Tomography in the Adult Cardiac Surgery Patient

Increasingly, computed tomography is requested for preoperative planning prior to cardiac surgery. Common pathologies, such as aortic and mitral annular calcification, can influence the choice of surgical technique or approach. In this article, we present a case-based review of primary and reoperative sternotomies that focuses on the clinical relevance of the common pathologies and findings in pre-operative computed tomography images, with respect to surgical decision-making and management.

Association of previous cardiac surgery with outcomes in left ventricular assist device patients

OBJECTIVES

History of prior cardiac surgery has traditionally been considered a risk factor for subsequent cardiac procedures. The aim of this study was to investigate the outcomes of patients implanted with a left ventricular assist device via redo sternotomy.

METHODS

Prospectively collected data were reviewed for all patients implanted with a continuous-flow left ventricular assist device at a single institution from December 2006 through June 2018. Patients were separated into 2 cohorts: those with a history of prior cardiac surgery (redo sternotomy) and those undergoing primary sternotomy at the time of left ventricular assist device implantation. The primary outcome was overall survival.

RESULTS

Of the 321 patients included in the study, 77 (24%) were implanted via redo sternotomy and 244 (76%) via primary sternotomy. The redo sternotomy cohort was generally older (59 ± 10 vs 57 ± 12 years, P = 0.050) and had a higher incidence of ischaemic disease (70% vs 49%, P = 0.002). The Kaplan-Meier survival analysis demonstrated that overall survival was not significantly different between the redo sternotomy and primary sternotomy groups (6-month survival: 86% vs 92%; 5-year survival: 53% vs 51%; log-rank P = 0.590 for overall difference during follow-up). The propensity score analysis consistently showed that redo sternotomy was not significantly associated with mortality risk (hazard ratio 1.19, 95% confidence interval 0.73-1.93; P = 0.488). Redo sternotomy patients were more likely to require rehospitalization during their first year postoperatively (P = 0.020) and spent less time out of the hospital during the first year (P = 0.046).

CONCLUSIONS

The redo sternotomy cohort represents a more technically challenging patient population, but overall survival similar to that of primary sternotomy patients can be achieved.

Minimally invasive beating heart technique for mitral valve surgery in patients with previous sternotomy and giant left ventricle

PURPOSE

To analyze the efficacy of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle.

METHODS

Eighty cardiac patients with previous sternotomy and giant left ventricle according to the diagnostic criteria that left ventricular end diastolic diameter (LVEDD) was ≥70 mm, who underwent mitral valve surgery at our center from January 2006 to January 2019 were analyzed. We divided all patients into minimally invasive beating heart technique group (n = 30) and conventional median resternotomy arrested heart technique group (n = 50) according to the surgical methods. Preoperative, intraoperative, and postoperative variables were compared between two groups.

RESULTS

Minimally invasive beating heart technique compared to the conventional median resternotomy arrested heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle had significant differences in operation time(P = 0.002), cardiopulmonary bypass (CPB) time(P < 0.001), intraoperative blood loss(P < 0.001), postoperative transfusion ratio(P = 0.01), postoperative transfusion amount(P < 0.001), postoperative drainage volume(P = 0.001), extubation time(P = 0.04), intensive care unit (ICU) stay time(P = 0.04) and postoperative hospital stay time(P < 0.001), but no significant differences in re-exploration for bleeding, postoperative 30-day mortality, postoperative complications and 6 months postoperative echocardiographic parameters.

CONCLUSIONS

Using the method of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle is effective and reliable, meanwhile reduce the operation time and CPB time, decrease the transfusion ratio and transfusion amount, shorten postoperative ICU stay and hospital stay time, promote the early extubation so that accelerate the patients' early recovery. All of these show a benefit of minimally invasive beating heart technique compared to conventional median resternotomy arrested heart technique.

Video-assisted thoracoscopic sternal adhesiolysis before resternotomy reduces morbidity and improves patient care

BACKGROUND

Resternotomy still carries an important risk for an already high-risk population. Re-entry injuries may lead to massive bleeding, which can be difficult to control due to poor accessibility. The aim of the study was to assess early outcomes of video-assisted thoracoscopic adhesiolysis, as well as safety and feasibility.

METHODS

Forty-five patients received a video-assisted thoracoscopic adhesiolysis before resternotomy between April 1, 2016 and January 1, 2019. Records were reviewed for demographics, perioperative and early postoperative (Postop) outcomes.

RESULTS

The median age of the population was 73 years with a EUROSCORE II of 8.322. Only 1 (2.22%) patient experienced a major and 2 (4.44%) a minor re-entry injury. This resulted in a mean peroperative and 24-hour Postop blood loss of, respectively, 675.72 (range: 5-2862) and 444.71 mL (range: 0-2100). There was no significant difference between the use of minimally invasive and classic extracorporeal circulation (P = .276 and P = .81, respectively). Twenty-nine patients (64%) were not in need of red blood cell transfusion. A survival rate of 93.33% could be achieved. No deaths (n = 3) were related to the video-assisted thoracoscopic adhesiolysis or re-entry injuries. Kidney function remained stale postoperatively with creatinine preoperative and Postop levels of 1.56 (95%confidence interval: 1.07-2.05) and 1.43 (95%CI, 1.05-1.81) mg/dL (P = .264). Despite high-risk surgery, the median length of stay was 8 days.

CONCLUSION

A video-assisted thoracoscopic approach allows for a safe and effective adhesiolysis, due to increased visibility and accuracy. This approach may prevent major and minor re-entry injuries and consequently reduce perioperative morbidity and mortality of high-risk surgery.

Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Purpose of review

Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence.

Recent findings

While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available.

Summary

We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.

Management of retrosternal adhesion after median sternotomy by controlling degradation speed of a dextran and ε-poly (L-lysine)-based biocompatible glue

OBJECTIVE

Retrosternal adhesion after median sternotomy possibly raises the risk of cardiac injury at resternotomy. A biodegradable glue "Lydex" is composed of food additives, dextran and ε-poly (L-lysine), and the degradation speed can be controlled by the composition. In the present study, we evaluated the preventative effect of Lydex on retrosternal adhesion and the relationship between degradation speed and the progression of retrosternal fibrosis.

METHODS

Japanese white rabbits are subjected to median sternotomy. Lydex 1, 2 and 3 were loaded at the retrosternal space of rabbits in allocated groups before sternal closure, respectively (n = 11 for each group). Retrosternal adhesion was macroscopically evaluated after surgery. Retainment of Lydex, retrosternal fibrosis and the infiltration of macrophages are histologically evaluated, respectively.

RESULTS

All Lydex groups exhibited less retrosternal adhesion at 4 weeks after loading compared to unloaded control. The degradation speed of Lydex varied according to the compositions. Lydex with faster degradation (Lydex 2 or Lydex 3) showed lower progression of retrosternal fibrosis compared to that with slower degradation (Lydex 1) [fibrosis ratio: control vs Lydex 1 vs Lydex 2 vs Lydex 3: 0.60 ± 0.15 vs 0.18 ± 0.17 vs 0.00 ± 0.00 vs 0.00 ± 0.00, P = 0.0005 (Lydex 1 vs Lydex 2), P = 0.0005 (Lydex 1 vs Lydex 3)]. Retrosternal infiltrations of macrophages in Lydex 1 and Lydex 3 groups are not higher compared to that in unloaded control.

CONCLUSIONS

The degradation speed of Lydex could be controlled according to the compositions. The degradation speed affected the progression of retrosternal fibrosis.

Use of Pericardium for Cardiac Reconstruction Procedures in Acquired Heart Diseases-A Comprehensive Review

BACKGROUND

Reconstruction of cardiac structures has been the goal of many surgeons even before the advent of open-heart procedures with cardiopulmonary bypass. Unsatisfactory results with synthetic materials has switched the attention to biological tissues, among which pericardium, either autologous or of animal origin, has been widely used as patch material.

METHODS

We have reviewed the literature to assess the effective role of pericardial tissue in the correction of various acquired cardiac lesions. Particularly, special attention was given not only to established techniques but also to detect any peculiar and unusual application of pericardium.

RESULTS

Autologous pericardium is frequently used as patch material particularly when limited valvular lesions must be corrected, while xenograft pericardium appears particularly useful in patients with endocarditis and extensive destruction of the intracardiac structures by infection and abscesses. Pericardium is an extremely versatile material owing to its pliability and strength; however, it tends to calcify in the long term when in contact with blood, although stability of the repair is maintained in most cases.

CONCLUSIONS

Pericardium plays an important role in various cardiac and aortic pathologies. Tissues resistant to fibrosis and calcification to be used as patch material are the ideal solution for more successful cardiac reconstruction procedures and will hopefully be provided by the ongoing research.

Primary graft dysfunction after heart transplantation: a thorn amongst the roses

Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.

Measurement of Adhesion of Sternal Wires to a Novel Bioactive Glass-Based Adhesive

Stainless steel wires are the standard method for sternal closure because of their strength and rigidity, the simplicity of the process, and the short healing time that results from their application. Despite this, problems still exist with sternal stability due to micromotion between the two halves of the dissected and wired sternum. Recently, a novel glass-based adhesive was developed which, in cadaveric trials and in conjunction with wiring, was shown to restrict this micromotion. However, in order to avoid complications during resternotomy, the adhesive should adhere only to the bone and not the sternal wire. In this study, sternal wires were embedded in 8 mm discs manufactured from the novel glass-based adhesive and the constructs were then incubated at 37 °C for one, seven, and 30 days. The discs were manufactured in two different thicknesses: 2 and 3 mm. Wire pull-out tests were then performed on the constructs at three different strain rates (1, 0.1, and 0.01 mm/min). No statistically significant difference in pull-out force was found regardless of incubation time, loading rate, or construct thickness. The pull-out forces recorded were consistent with static friction between the wire and adhesive, rather than the adhesion between them. Scanning electron micrographs provided further proof of this. These results indicate that the novel adhesive may be suitable for sternal fixation without complicating a potential resternotomy.

MDCT prior to median re-sternotomy in cardiovascular surgery: our experiences, infrequent findings and the crucial role of radiological report

Resternotomy (RS) is a common occurrence in cardiac surgical practice. It is associated with an increased risk of injury to old conduits, cardiac structures, catastrophic hemorrhage and subsequent high morbidity and mortality rate in the operating room or during the recovery period. To mitigate this risk, we evaluated the role of multidetector CT (MDCT) in planning repeat cardiac surgery. We evaluated sternal compartment abnormalities, sternal/ascending aorta distance, pre-reoperative assessment of the aorta (wall, diameters, lumen, valve), sternal/right ventricle distance, diaphragm insertion, pericardium and cardiac chambers, sternal/innominate vein distance, connection of the grafts to the predicted median sternotomy cut, graft patency and anatomic course, possible aortic cannulation and cross-clamping sites and additional non-cardiovascular significant findings. Based on the MDCT findings, surgeons employed tailored operative strategies, including no-touch technique, clamping strategy and cardiopulmonary bypass (CPB) via peripheral cannulation assisted resternotomy. Our experience suggests that MDCT provides information which contributes to the safety of re-operative heart surgery reducing operative mortality and adverse outcomes. The radiologist must be aware of potential surgical options, including in the report any findings relevant to possible resternotomy complications.

Impact of failed mitral valve repair on hospital outcome of redo mitral valve procedures

OBJECTIVES

The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated.

METHODS

Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses.

RESULTS

A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P  = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR.

CONCLUSIONS

A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome.

Previous Sternotomy as a Risk Factor in Minimally Invasive Mitral Valve Surgery

Background

Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation.

Methods

We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis.

Results

Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk.

Conclusion

A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.

Resternotomy does not adversely affect outcome after left ventricular assist device implantation

Background

Resternotomy in cardiac surgery is considered a risk factor for postoperative complications. Previous studies have demonstrated an ambiguous relationship between resternotomy and clinical outcomes. Registry data from a mixed population of durable circulatory support devices suggest that history of cardiac surgery is a risk factor for mortality. Our study investigates the prognostic significance of resternotomy in a homogenous cohort of left ventricular assist device (LVAD) recipients.

Methods

The study included adult patients receiving a continuous-flow LVAD at our institution during the period 2010–2016. Postoperative adverse events and length of stay were analyzed. Survival was assessed at 6 months and by the end of the study. Multivariate risk factor analysis was conducted for independent predictors of death.

Results

One hundred twelve patients, who received an intrapericardial LVAD (HVAD, HeartWare), were included in our analysis. Twenty-four patients (21.4%) had a history of previous sternotomy. These patients were older and non-eligible for bridging, and had more frequently coronary heart disease. Univariate analysis demonstrated no differences in the observed complications postoperatively. Survival was similar among groups. Destination therapy was the only predictor of mortality in our analysis (p = 0.02).

Conclusions

Resternotomy was not associated with worse outcomes after LVAD implantation in our cohort.

Binding of Anticell Adhesive Oxime-Crosslinked PEG Hydrogels to Cardiac Tissues

Postsurgical cardiac adhesions increase the number of surgeries as well as patient mortality and morbidity. A fast gelling oxime-crosslinked PEG hydrogel with tunable gelation time, degradation, and mechanical properties is presented. This material is cytocompatible and prevents cellular adhesion. Material retention on different cardiac tissues is demonstrated ex vivo over time and that functional group ratio alters material retention on different cardiac tissues.

Surgical results of third or more cardiac valve operation

Background

We evaluated operative outcomes after third or more cardiac operations for valvular heart disease, and analyzed whether pericardial coverage with artificial membrane is helpful for subsequent reoperation.

Methods

From 2000 to 2012, 149 patients (male: female=70: 79; mean age at operation, 57.0±11.3 years) underwent their third to fifth operations for valvular heart disease. Early results were compared between patients who underwent their third operation (n=114) and those who underwent fourth or fifth operation (n=35). Outcomes were also compared between 71 patients who had their pericardium open during the previous operation and 27 patients who had artificial membrane coverage.

Results

Intraoperative adverse events occurred in 22 patients (14.8%). Right atrium (n=6) and innominate vein (n=5) were most frequently injured. In-hospital mortality rate was 9.4%. Total cardiopulmonary bypass time (225±77 minutes vs. 287±134 minutes, p=0.012) and the time required to prepare aortic cross clamp (209±57 minutes vs. 259±68 minutes, p<0.001) increased as reoperations were repeated. However, intraoperative event rate (13.2% vs. 20.0%), in-hospital mortality (9.6% vs. 8.6%) and postoperative complications were not statistically different according to the number of previous operations. Pericardial closure using artificial membrane at previous operation was not beneficial in reducing intraoperative events (25.9% vs. 18.3%) and shortening operation time preparing aortic cross clamp (248±64 minutes vs. 225±59 minutes) as compared to no-closure.

Conclusion

Clinical outcomes of the third or more operations for valvular heart disease were acceptable in terms of intraoperative adverse events and in-hospital mortality rates. There were no differences in the incidence of intraoperative adverse events, early mortality and postoperative complications between third cardiac operation and fourth or more.

Redo mitral valve replacement through a right mini-thoracotomy with an unclamped aorta

Redo cardiac surgery represents a clinical challenge due to a higher rate of perioperative morbidity and mortality. Mitral valve (MV) re operations can particularly be demanding in patients with patent coronary grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, leaks or thrombosis). In this article we describe our technique to manage complex mitral reoperations using a minimally invasive approach, moderate hypothermia and avoiding aortic cross-clamping. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of less invasive access and continuous myocardial perfusion. The advantage of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, reducing the risk of cardiac structures or patent graft injury. Moderate hypothermia and continuous blood perfusion can guarantee adequate myocardial protection particularly in the case of patent grafts, decreasing the dangers of an incomplete or imperfect aortic clamping at mild hypothermia and potential lesions due to demanding clamp placing. Complex MV reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space with an unclamped aorta.

Minimally invasive approach for redo mitral valve surgery

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative†

OBJECTIVES

Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR.

METHODS

Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis].

RESULTS

Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04).

CONCLUSIONS

RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases.

Beating heart mitral valve repair for a patient with previous coronary bypass: a case report and review of the literature

Mitral valve reoperation, through a median sternotomy, for a patient with patent coronary bypass grafts is technically challenging and carries higher postoperative morbidity and mortality than a primary operation. We present a case of mitral valve repair using a beating heart technique under normothermic cardiopulmonary bypass that was performed 3 years after a coronary artery bypass operation. A limited (10 cm) right thoracotomy was made and cardiopulmonary bypass was conducted using the ascending aortic and femoral venous cannulation. The left atrium was opened while beating was maintained. Triangular resection of the prolapsed portion of the posterior leaflet and ring annuloplasty were performed. Completeness of the repair was verified by direct visualization under beating condition and transesophageal echocardiogram. This technique is a safe and feasible option for a mitral valve reoperation that excludes re-sternotomy, extensive pericardial dissection and aortic clamping, thereby minimizes risks of bleeding, graft injury and myocardial damage.

A review of the current status of pericardial closure following cardiac surgery

Some cardiac surgeons prefer to close the pericardium whenever possible following surgery, others specifically avoid this practice, and still others believe that neither alternative has any meaningful influence on clinical outcomes. Unfortunately, scientific evidence supporting either approach is scarce, making a consensus regarding best practice impossible. In this article, the known functions of the native intact pericardium are summarized, and the arguments for and against pericardial closure after surgery are examined. In addition, the techniques and materials that have been utilized for pericardial closure previously, as well as those that are currently being developed, are assessed.

Is resternotomy a risk for continuous-flow left ventricular assist device outcomes?

BACKGROUND

The number of patients undergoing resternotomy continues to rise. Although catastrophic hemorrhage remains a dreaded complication, most published data suggest that sternal reentrance is safe, with negligible postoperative morbidity and mortality. A significant proportion of left ventricular assist device (LVAD) implantations are reoperative cardiac procedures. The aim of our study was to compare outcomes between first time sternotomy and resternotomy patients receiving continuous-flow LVADs, as a bridge to transplantation or destination therapy.

METHODS AND MATERIALS

From March 2006 through February 2012, 100 patients underwent implantation of a HeartMate II or HeartWare LVAD at our institution. Patients were stratified into two groups, primary sternotomy and resternotomy. Variables were compared using two-sided t-tests, chi-square tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the two groups and if resternotomy was a significant independent predictor of outcome.

RESULTS

We identified 29 patients (29%) who had resternotomy and 71 patients (71%) who had first time sternotomy. The resternotomy group was significantly older (56 years vs. 51 years, p = 0.05), was more likely to have ischemic cardiomyopathy (ICM) (69% vs. 30%, p < 0.001), chronic obstructive pulmonary disease (COPD) (31% vs. 14%, p = 0.05) and had longer cardiopulmonary bypass times (135 min vs. 100 min, p = 0.011). Survival rates at 30 days (93.1% vs. 95.8%, p = 0.564), 180 days (82.8% vs. 93%, p = 0.131), and 360 days (82.8% vs. 88.7%, p = 0.398) were similar for the resternotomy and primary sternotomy groups, respectively. Postoperative complications were also comparable, except for re-exploration for bleeding which was higher for the resternotomy group (17.2% vs. 4.2%, p = 0.029), although blood transfusion requirements were not significantly different (1.4 units vs. 1.2 units, p = 0.815). Left and right heart catheterization measurements and echocardiographic (ECHO) findings after 1 and 6 months of LVAD therapy were similar between the two groups.

CONCLUSIONS

Survival at 30, 180, and 360 days after LVAD implantation is similar between the resternotomy and primary sternotomy group. No major differences in complications or hemodynamic measurements were observed. Although a limited observational study, our findings agree with previously published resternotomy outcomes.