753 Should Mini-Sternotomy Be Favoured Over Conventional Full-Sternotomy Approach in Aortic Valve Replacement

Aim

In view of the increasing interest in Upper mini-sternotomy (UMS) as an alternative approach for conventional full sternotomy AVR (FS), we aimed to compare early and mid-term results between UMS and Full-sternotomy AVR.

Method

This is a retrospective study of 231 patients who had aortic valve replacement via upper mini sternotomy (UMS) compared with 231 patients had their AVR via full sternotomy (FS). Baseline characteristics, operative and postoperative outcomes were compared. Patients’ data are presented as median (interquartile range) or as percentages.

Results

The two groups were almost comparable in terms of preoperative characteristics. Though patients with age >80 were more in UMS AVR group (11.25% vs 8.6%), this was statistically insignificant (p > 0.05). Females were significantly more in UMS AVR group (104 vs 66, p < 0.05), as well as in high BMI patients (120 vs 89, p < 0.05). There was no significant difference in 30-day mortality( 0.43%vs 2.2%, P > 0.05) between the two groups, as well as in cardiopulmonary bypass time (109 vs 103 min, p > 0.05), aortic cross-clamping time (82 vs 83 min, p > 0.05) and the duration of operation(218 vs 213, p > 0.05).Results showed no significant difference in the incidence of major and minor postoperative complications apart from FS AVR patients had a higher incidence of postoperative pneumonia ( 2.1% vs 10.4 %, p < 0.05).

Conclusions

UMS AVR are more commonly used in females and high BMI patients. Our results show that UMS AVR is a safe alternative approach for aortic valve surgery revealing comparable early and midterm results to conventional FS AVR.

Management of Blunt Thoracic Aortic Injury

Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.

A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting

We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (general anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded-eight in Group TEA and four in Group GA-because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.