Explore the vast range of titles available.

The mid-point transverse process to pleura block (MTPB) is a new variant of thoracic paravertebral block (TPVB). This study aimed to compare TPVB and MTPB with respect to intraoperative attenuation of the hemodynamic stress response to surgery and postoperative analgesia in pediatric open heart surgery with midline sternotomy. A single-center, randomized, controlled, double-blind, non-inferiority study. Tertiary care children's university hospital. We recruited 83 children aged 2–12 years of both sexes with American Society of Anesthesiologists (ASA) physical status class II who were scheduled for elective open cardiac surgeries with midline sternotomy for the repair of simple noncyanotic congenital heart defects. Eligible participants were randomized into either the TPVB or MTPB groups at a ratio of 1:1. In the TPVB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine in the paravertebral space at T4 and T5. In the MTPB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine mid-transverse process and pleura just posterior to superior costotransverse ligament at the level of T4 and T5. The primary outcome was the hemodynamic responses to sternotomy incision, including heart rate (HR) and invasive mean arterial pressure (MAP), recorded before and after the induction of anesthesia, after skin incision, after sternotomy, 15 min after cardiopulmonary bypass (CPB), and after the closure of the sternum. The secondary outcomes were time needed to perform the bilateral block, intraoperative fentanyl consumption, postoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 2, 6, 12, 18, and 24 h after extubation, extubation time, intensive care unit (ICU) discharge time, and the incidence of non-surgical complications (postoperative pruritus, postoperative vomiting, pneumothorax, hematoma or local anesthetic toxicity). There were no significant differences in HR and MAP in the TPVB group compared with the MTPB group at the following time points: baseline, after induction, after skin incision, after sternotomy, 15 min after CPB, and after sternal closure. Intergroup comparisons of HR and MAP did not reveal significant differences between the groups. The median (IQR) time needed to perform bilateral MTPB (7[6–8] min) was significantly (p < 0.001) shorter than that of TPVB (12[10−13] min). Intraoperative fentanyl consumption and fentanyl consumption in the first postoperative 24 h after extubation were similar in the TPVB and MTPB groups (4[2–4] vs 4[2–4] and 4.66 ± 0.649 vs 4.88 ± 1.082 μg/kg), respectively. Extubation time and ICU discharge time were comparable in the TPVB and MTPB groups (2[1–3] vs 2[1–3] h and 21.2 ± 2.5 vs 20.8 ± 2.6 h), respectively. Measurements of MOPS pain scores at 1, 2, 6, 12, 18, and 24 h after extubation were similar in both groups. The incidence of nonsurgical complications was similar in both groups. MTPB is non-inferior to TPVB in attenuating the intraoperative hemodynamic stress response to noxious surgical stimuli and in reducing perioperative opioid consumption, extubation time, and ICU discharge time. Moreover, MTPB is technically easier than TPVB and requires less time to perform. Clinical trial registration number The clinical trial registration was prospectively performed at the Pan African Clinical Trials Registry (PACTR202204901612169, approval date 01/04/2022, URL https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=22602). •Mid-point transverse process to pleura block (MTPB) is a new variant of thoracic paravertebral block (TPVB).•The effectiveness of TPVB in blunting hemodynamic stress response and postoperative analgesia is well-established.•MTPB is non-inferior to TPVB in attenuation surgical hemodynamic stress response and providing perioperative analgesia.

PurposePostoperative pain after cardiac surgery, exacerbated by cough and sternal mobilization, limits clearance of bronchopulmonary secretions and may predispose to postoperative pneumonia. In this study, we tested the ability of local anesthetic continuous wound infusion to prevent pneumonia after cardiac surgery with sternotomy and cardiopulmonary bypass (CPB) owing to better analgesia and bronchopulmonary drainage.MethodsIn this randomized, double-blind, placebo-controlled trial conducted in five academic centers, patients undergoing cardiac surgery with sternotomy and CPB were enrolled from February 2012 until November 2014, and were followed over 30 days. Patients were assigned to a 48-h infusion (10 ml h−1) of l-bupivacaine (12.5 mg h−1) or placebo (saline) via a pre-sternal multiperforated catheter. Anesthesia and analgesia protocols were standardized. The primary end point was the incidence of pneumonia during the study period, i.e., until hospital discharge or 30 days. We hypothesized a 30% reduction in the incidence of pneumonia.ResultsAmong 1493 randomized patients, 1439 completed the trial. Pneumonia occurred in 36/746 patients (4.9%) in the l-bupivacaine group and in 42/739 patients (5.7%) in the placebo group (absolute risk difference taking into account center and baseline risk of postoperative pneumonia, − 1.3% [95% CI − 3.4; 0.8] P = 0.22). In the predefined subgroup of patients at high risk, l-bupivacaine decreased the incidence of pneumonia (absolute risk difference, − 5.6% [95% CI − 10.0; − 1.1], P = 0.01).ConclusionsAfter cardiac surgery with sternotomy, continuous wound infusion of l-bupivacaine failed to decrease the incidence of pneumonia. These findings do not support the use of local anesthetic continuous wound infusion in this indication. Further study should investigate its effect in high-risk patients.Trial registrationEudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.

Reoperative cardiac surgery is associated with a higher risk of complications due to technical difficulties compared to the first-time surgery. This study aims to compare the early outcomes of median sternotomy (MS) and lateral thoracotomy (LT) procedures in patients with a history of previous open-heart surgery who underwent left ventricular assist device (LVAD) implantation with cardiopulmonary bypass (CPB). A retrospective analysis was conducted on 36 patients who received LVAD implants for end-stage heart failure between November 2012 and June 2015. The patients were divided into Group 1 (MS, n = 18) and Group 2 (LT, n = 18). The mean age of the patients was 57.2 ± 9.4 years (range: 24 - 70 years), and only 8.3% were female. Demographic data, preoperative characteristics, use of blood products, anesthetic drugs, and complications were similar in both groups (P > 0.05). The MS group had significantly longer operation duration (101 ± 46 minutes vs. 70 ± 20 minutes, P = 0.038) and CPB time (328 ± 79 minutes vs. 265 ± 47 minutes, P = 0.048) compared to the LT group. Postoperative analgesic consumption and pain scores were similar between the two groups (P > 0.05). In patients with a history of previous cardiac surgery, LVAD implantation with LT through CPB demonstrated favorable outcomes regarding reduced operation duration and CPB time. However, it did not positively impact the duration of stay in the intensive care unit, hospital stay, use of blood products, and complications.

BackgroundLinear hypertrophic scar is a common surgical problem that can be difficult to manage, especially for the median sternotomy scar. Botulinum toxin type A (BTA) is widely used in cosmetic surgery and has been shown to improve scar quality recently. The aim of this study was to evaluate the efficacy of BTA injected in the early postoperative of median sternotomy on preventing scar formation.MethodsIn this prospective randomized controlled trial, 19 consecutive patients who underwent median sternotomy were enrolled. The median sternotomy wound in each patient was divided into the upper half and the lower half. Both halves of the wound were randomized to receive the treatment with either BTA or normal saline. At 6-month follow-up, scars were assessed using the Vancouver Scar Scale, scar widths were measured, and patients were asked to evaluate their overall satisfaction.ResultsSeventeen patients with median sternotomy wounds completed the entire study. At 6-month follow-up, the mean Vancouver Scar Scale score for the BTA-treated group was 3.44 ± 1.68 and for the normal saline control group was 6.29 ± 2.39, and there was a statistically significant difference between the two groups (P < 0.05). There were also significant improvements in scar width and patient satisfaction for the BTA-treated halves of the wounds (P < 0.05).ConclusionsThe study demonstrates that early postoperative BTA injection can decrease scar formation and reduce scar width in median sternotomy wounds, and the overall appearance is more satisfactory.Level of Evidence IThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Minimally invasive techniques for aortic valve replacement have become increasingly popular. The most common minimally invasive approaches are mini-sternotomy and right anterior mini-thoracotomy. We aimed to review the literature and compare clinical outcomes for these two approaches. Three databases were assessed. The primary endpoint was perioperative mortality. The secondary endpoints were reoperation for bleeding, stroke, operation duration, intensive care unit length of stay, cardiopulmonary bypass time, cross-clamping time, hospital length of stay, paravalvular leak, renal complications, conversion to full sternotomy, permanent pacemaker implantation, and wound infection. Random effects models were performed. Ten studies were included in the meta-analysis (30,524 patients). There was no difference in perioperative mortality between groups (odds ratio: 0.83; 95% confidence interval 0.57-1.21; P=0.33). In comparison with mini-sternotomy, right anterior mini-thoracotomy showed higher rates of reoperation for bleeding (odds ratio: 0.69; 95% confidence interval 0.50-0.97; P=0.03), lower rates of stroke (odds ratio: 1.27; 95% confidence interval 1.01-1.60; P=0.04), and longer operation duration (standard mean difference: -0.58; 95% confidence interval -1.01 to -0.14; P=0.01). Other secondary endpoints were not statistically significant. The results suggest that both techniques present similar perioperative mortality rates for aortic valve replacement. However, right anterior mini-thoracotomy is associated with higher rates of reoperation for bleeding, lower rates of stroke, and longer operation duration time.

Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified. We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI,  -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks. The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required. PROSPERO (CRD42022306914); first submitted 22 March 2022.

Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques.

In this study, we aimed to compare the outcomes of left anterior mini-thoracotomy and conventional sternotomy in on-pump multivessel coronary revascularization. Two hundred sixty-two patients who underwent minimally invasive coronary artery bypass grafting through the left anterior mini-thoracotomy and conventional coronary artery bypass grafting with full sternotomy were included. All patients were divided into two groups - 132 patients who underwent minimally invasive multivessel coronary artery bypass grafting in Group I, and 130 patients with full sternotomy in Group II. Intraoperative variables (cross-clamping time, cardiopulmonary bypass time, etc.), postoperative parameters (drainage amount, revision, intensive care and hospital stay times, etc.), and mortality were analyzed retrospectively. Cardiopulmonary bypass time (152.24 ± 36.4 minutes) was significantly longer in Group I than in Group II (102.24 ± 19.4 minutes) (P<0.001). Cross-clamping time (86 ± 13.2 minutes) was significantly longer in Group I than in Group II (62 ± 21.4 minutes) (P<0.001). And intensive care stay time (P=0.005) and hospital stay time (P=0.004) were significantly shorter in Group I. In the postoperative period, six patients in Group I and seven patients in Group II were revised due to bleeding. Total perioperative mortality was one patient in both groups (P=0.82). Multivessel coronary artery bypass grafting through the left anterior mini-thoracotomy is an effective, reliable, and successful method, due to less drainage amount and less blood transfusion need, shorter intensive care and hospital stays, faster return to daily life, and better cosmetic results compared to conventional methods.

Background: The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the usual full sternotomy Bentall procedure (Usual Bentall-DeBono procedure). Objective: This study evaluates the efficacy and safety of mini sternotomy aortic root surgery (MSARS), a minimally invasive technique designed to reduce surgical trauma, improve postoperative recovery, and lower healthcare costs. Methods: The upper mini sternotomy (UMS) approach was performed in ten patients focusing on standardized surgical procedures, and rigorous postoperative care. Key findings indicate that MSARS markedly reduces postoperative complications, ICU stay, and overall hospital stay compared to traditional sternotomy. Results: The median postoperative length of stay was seven days for MSARS versus 11 days for traditional sternotomy, with ICU stays of 27 hours and 105 hours, respectively. Our study also highlights the cost-effectiveness of MSARS, with decreased hospital costs per patient due to reduced ICU resource utilization and shorter hospital stays. These findings suggest that MSARS is a valuable and advantageous alternative to traditional sternotomy, offering substantial benefits in terms of patient outcomes and healthcare efficiency. Conclusion: Mini sternotomy aortic root surgery via partial upper sternotomy could be a safe alternative to the full median sternotomy, marking a significant advancement in the field of cardiac surgery.