Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

Efficacy of Aortic Valve Replacement through Full Sternotomy and Minimal Invasion (Ministernotomy)

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

Pulmonary Valve Replacement With Balloon-Expandable Prosthesis Under Direct Vision: A Novel Therapeutic Approach

A 57-year-old woman with a history of pulmonary atresia with ventricular septal defect and hypoplastic pulmonary arteries was referred for a fifth redo sternotomy for right ventricular outflow conduit replacement. Traditional pulmonary valve replacement was aborted during the procedure because of heavy calcification, and the pulmonary valve was replaced with a SAPIEN XT stent valve under direct vision. We believe this is the first application of a balloon-expandable stent valve in the pulmonary valve position under direct vision. It provides a novel therapeutic approach to recurrent pulmonary valve dysfunction in adult congenital heart diseases.

Management of a pneumopericardium due to penetrating trauma

INTRODUCTION

A pneumopericardium presenting after penetrating chest trauma is a rare event. The surgical management of this clinical problem has not been clearly defined. The aim of this study was to document the mode of presentation and to suggest a protocol for management.

PATIENT AND METHODS

A review of a prospectively collected cardiac database of patients presenting to Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 with a pneumopericardium on chest X-ray after penetrating trauma.

RESULTS

There were 27 patients with a pneumopericardium (mean age 25 years, range 17-36). The mechanism of injury was a stab wound to the chest in 26 patients and a single patient with multiple low velocity gunshot wounds. Six patients (22%) were unstable and required emergency surgery. One of these patients presented with a tension pneumopericardium. Twenty-one patients were initially stable. Two of these (10%) patients later developed a tension pneumopericardium within 24-h and were taken to theatre. The remaining 19 patients were managed with a subxiphoid pericardial window (SPW) at between 24 and 48h post admission. Ten of these 19 patients (52%) were positive for a haemopericardium. Only 4 of the 19 underwent a sternotomy and only two of these had cardiac injuries that had sealed. There were no deaths in this series.

CONCLUSION

Patients with a penetrating chest injury with a pneumopericardium who are unstable require emergency surgery. A delayed tension pneumopericardium developed in 10% of patients who were initially stable. It is our recommendation that all stable patients with a pneumopericardium after penetrating chest trauma should undergo a SPW. A sternotomy is not required in stable patients.

University of Pennsylvania Lung Transplantation: update 2012

The University of Pennsylvania is committed to providing the highest level of longitudinal care to patients with end stage lung disease who pursue and undergo lung transplantation. Since 1991, the Penn Lung Transplant Program has performed over 800 lung, heart/lung, lung/liver, and redo lung transplants. As a result of this experience, we believe in a careful, deliberate approach to patients throughout all phases of care and encourage active participation of patients and their support systems throughout this process. We aim to continue to be leaders in the field of transplant related research, with goals of improving short- and long-term outcomes and safely allowing this procedure to be made available to more patients who need it. This chapter provides an overview of our program structure and philosophy towards patient evaluation, as well as highlights the unique aspects of our program.

Mini-sternotomy aortic valve replacement: is it safe and effective? Comparison with standard techniques

BACKGROUND AND AIM OF THE STUDY

Mini-sternotomy aortic valve replacement (MSAVR) has been increasingly performed at the authors' institution since October 2003. The study aim was to compare results obtained with MSAVR to those following AVR with conventional sternotomy (SAVR).

METHODS

Between 1998 and 2008, a total of 143 consecutive patients (mean age: 67 +/- 12.5 years) underwent AVR at the authors' institution. Of these patients, 82 underwent SAVR, and 61 underwent MSAVR performed through a reversed-L-shaped median sternotomy with a transverse limb at the right fourth intercostal space. Ascending aortic and right atrial cannulation through the mini-sternotomy were employed for cardiopulmonary bypass (CPB).

RESULTS

Typically, the MSAVR patients were slightly younger than SAVR patients (mean age: 67 +/- 16 years and 70 +/- 15 years, respectively; p = 0.037), had a lower incidence of diabetes (3% versus 18%, p = 0.008), and a slightly higher left ventricular ejection fraction (74.5 +/- 12% versus 71 +/- 12%, p = 0.019). There were no other inter-group preoperative differences. As expected, MSAVR required a slightly longer aortic cross-clamp time (49 +/- 19 min) compared to SAVR (44.5 +/- 16 min; p = 0.019), and longer CPB times (77 +/- 31 min versus 60 +/- 26 min; p <0.0001), though the overall operating times were similar (p = 0.38). Postoperatively, MSAVR patients were extubated at 3 +/- 5 h, similar to SAVR patients (4 +/- 5 h) (p = 0.13). The median intensive therapy unit stay was 1 +/- 1 days in both groups. The median hospital stay was comparable between groups (MSAVR, 7 +/- 5 days; SAVR, 8 +/- 4 days; p = 0.48). The MSAVR patients had a higher incidence of delayed pericardial effusions requiring pericardiocentesis (n = 4; p = 0.031), but this did not affect survival. The 30-day mortality was similar in both groups (MSAVR group, n = 1 (1.6%); SAVR group, n = 3 (3.7%); p = 0.64). At five years after surgery, freedom from cardiac-related death was 96 +/- 2.6% in MSAVR patients, and 89 +/- 4.9% in SAVR patients (p = 0.32).

CONCLUSION

Mini-sternotomy AVR is technically challenging with longer CPB and aortic cross-clamp times. However, with increasing surgical experience, it offers results comparable to those achieved with conventional AVR, and with acceptable cosmetic results.

Sternal wound infections: improvements made to reduce rates

Wound infections from surgical sites account for 15% of all healthcare-associated infections (National Institute for Health and Clinical Excellence (NICE), 2008). There is evidence that the care provided before and after the operation is paramount to minimize the risk of surgical site infection. Sternal wound infections lengthen hospital stays (or prompt readmission) and carry a high mortality rate. In August 2009 a Manchester Hospital discovered a cluster of three patients with sternal wound infections. A review of clinical data for patients having cardiac surgery from 1 December 2008 and 9 October 2009 revealed an increased incidence of patients with sternal wound infections. The data did not reveal a significant problem, but one that should be kept under observation. During the investigation no single pathogen had been identified as responsible and no obvious source of environmental infection was identified. Implementing additional infection prevention and control practices helped the hospital team to improve the care given to patients. A host of factors, ranging from providing more information on wound care to patients, improving audit scores, and adhering to NICE guidelines, contributed to the reduction in this type of surgical site infection.