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Purpose Postoperative 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. Methods In 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. Results Among 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). Conclusions After 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 registration EudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.

Background To compare the outcomes of mitral and/or tricuspid valve surgery in patients with previous sternotomy between those who underwent a right thoracotomy and those who underwent re-sternotomy. Methods Between October 2009 and May 2015, eighteen patients underwent a right thoracotomy (R group) and 28 underwent re-sternotomy (re-S group). The right thoracotomy was prioritized for previous coronary artery bypass grafting. Follow-up was 100 % complete with a mean follow-up of 1.9 ± 1.5 years for the R group and 2.5 ± 1.4 years for the re-S group ( p  = 0.2137). Results Hypothermic ventricular fibrillation was applied in 33.3 % in the R group and in 7.1 % in the re-S group ( p  =  0.0424 ). Hospital mortality, the median intensive care unit stay, and the median postoperative hospital stay were 0 % versus 7.1 % ( p  = 0.5130), 3 days versus 2 days ( p   =  0.2370), and 28 days versus 29.5 days ( p  = 0.8043) for the R group versus the re-S group, respectively. Although the rate of major complications was comparable (R group 33.3 % versus re-S group 25.0 %, p  = 0.5401), those contents were not equal. Deep sternum infection developed only in the re-S group (3.6 %) and reoperation for bleeding was required only in the R group (11.1 %). No significant difference was observed in the 2-year cardiac-related mortality-free rate (R group 93.3 ± 6.4 % versus re-S group 90.8 ± 6.4 %, p  = 0.7516). Conclusions Given study limitations, the right thoracotomy approach after previous sternotomy provided favorable outcomes as well as re-sternotomy. When selecting a right thoracotomy for re-do mitral and/or tricuspid surgery, the surgical strategy needs to be thoroughly planned.

Background Coronary artery by-pass grafting (CABG) remains the optimal strategy in achieving complete revascularization in patients with complex coronary artery disease. However, sternal wound infections (SWI), especially deep SWI are potentially severe complications to the surgery. At the department of cardiothoracic surgery in Uppsala University Hospital a gradual increase in all types of SWI occurred, which peaked in 2009. This prompted an in-depth revision of the whole surgical process. To monitor the frequency of post-operative infections all patients receive a questionnaire that enquires whether any treatment for wound infection has been carried out. Methods All patients operated with isolated CABG between start of 2006 and end of 2012 were included in the study. 1515 of 1642 patients answered and returned the questionnaire (92.3 %). The study period is divided into the time before the intervention program was implemented (2006-early 2010) and the time after the intervention (early 2010- end 2012). To assess whether potential differences in frequency of SWI were a consequence of change in the characteristics of the patient population rather than an effect of the intervention a retrospective assessment of medical records was performed, where multiple of the most known risk factors for developing SWI were studied. Results We noticed a clear decrease in the frequency of SWI after the intervention. This was not a consequence of a healthier population. Conclusions Our results from implementing the intervention program are positive in that they reduce the number of SWI. As several changes in the perioperative care were introduced simultaneously we cannot deduce which is the most effective.

Background Postoperative pain management after cardiac surgery involves a multimodal approach. Recently, the erector spinae plane (ESP) block has been incorporated into multimodal pain control protocols. These measures have been taken to increase patient satisfaction while minimizing opioid usage. Prospective data is lacking to guide decisions regarding optimal regional anesthetic agents. This randomized controlled pragmatic trial protocol seeks to determine the benefit of liposomal bupivacaine relative to plain bupivacaine hydrochloride at reducing postoperative opioid consumption and other clinical outcomes following cardiac surgery. Methods The investigators anticipate consenting 150 subjects to obtain 96 evaluable subjects undergoing minithoracotomy ( N  = 24 liposomal bupivacaine, N  = 24 bupivacaine hydrochloride) or open sternotomy ( N  = 24 liposomal bupivacaine, N  = 24 bupivacaine hydrochloride). The primary outcome will be postoperative opioid consumption, reported in morphine equivalents. Secondary outcomes will include postoperative nonopioid analgesic consumption, inpatient and outpatient postoperative pain scores, 30-day mortality and major morbidity rates, postoperative quality of life, and hospitalization costs. Double blinding will be conducted with necessary measures taken to mask electronic medical records and drug preparation. Discussion The trial is currently enrolling subjects at a single academic medical center in the northeastern United States. The current study aims to investigate the postoperative pain reported by patients undergoing cardiac surgery when receiving ESP blocks with liposomal bupivacaine (experimental) compared to its hydrochloride formulation (control). Trial registration ClinicalTrials.gov NCT06077422. Registered on October 2023.  https://clinicaltrials.gov/study/NCT06077422?tab=table .

Coronary artery bypass grafting (CABG) via sternotomy remains the standard of care for multivessel coronary disease. Minimally invasive cardiac surgery for coronary artery bypass grafting (MICS-CABG) is an evolving technique with the potential to reduce surgical trauma and promote faster recovery without compromising outcomes. This protocol describes a pilot randomized controlled trial comparing MICS-CABG and conventional CABG in multivessel patients in a high-volume tertiary center. This is a single-center, prospective, randomized controlled pilot trial. A total of 100 patients with multivessel coronary artery disease will be randomized (1:1) to undergo either conventional CABG via median sternotomy or MICS-CABG through a left anterior thoracotomy. The sample size of 100 patients (50 per group) was defined based on feasibility and statistical precision. This allows estimation of an expected 8% major adverse cardiovascular and cerebrovascular events (MACCE) rate with a 95% confidence interval half-width of ±5% in each group. These data will inform sample size calculations for a future phase III trial. The primary outcomes are safety and feasibility. Feasibility will be assessed by the successful completion of the planned minimally invasive coronary revascularization strategy. Safety will be evaluated through the occurrence of MACCE within 30 days postoperatively. Secondary outcomes include operative time, mechanical ventilation time, conversion rate to sternotomy, bleeding volume, atrial fibrillation, postoperative ICU and hospital length of stay, and patient-reported quality of life (EQ-5D-5L) 6 months postoperatively. The trial is ongoing at this moment. The protocol was approved by the Institutional Research Ethics Committee under que number CAAE: 54175921.8.0000.0068. Results will be disseminated through peer-reviewed publications and scientific conferences. ClinicalTrials.gov NCT06794359.

Background Recent guidelines for perioperative care in cardiac surgery recommend multimodal pain management to decrease opioid use. We evaluated the effect of multimodal pain management including parasternal intercostal nerve block on pain control and opioid use in patients who underwent coronary artery bypass grafting (CABG) requiring sternotomy and cardiopulmonary bypass. Study Design Medical records of consecutive patients who underwent CABG from 2018 to 2019 at Huntington Hospital were retrospectively queried. Patients were divided in 2 groups based on whether an Enhanced Recovery After Surgery (ERAS) pain management protocol including parasternal intercostal nerve blocks was employed. Outcomes, including length of stay, pain scores, and opioid use, were compared. Results There was no difference in length of stay (days) 5.43 vs. 5.38 (P = .45 and average pain score 2.23 vs. 3.27 (P = .137) for patients in the ERAS and non-ERAS groups. Maximum pain score, 7.74 to 6.15 (P = .015), and opioid use (total morphine mg equivalent), 149.64 to 32.01 (P < .01), were reduced in the ERAS group. Conclusion The ERAS multimodal pain management protocol utilizing intraoperative parasternal blocks appears to reduce pain and decrease opioid use after CABG.

Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p  < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p  = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.

Background Use of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach. Methods We retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group ( n  = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups. Results Hospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p  = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p  = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p  = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p  = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p  = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p  = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p  = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p  = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups ( p  = 1.000). Conclusion The upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

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

Background Mitral valve (MV) surgery has traditionally been performed by conventional sternotomy (CS), but more recently minimally invasive surgery (MIS) has become another treatment option. The aim of this study is to compare short- and long-term results of MV surgery after CS and MIS. Methods This study was a retrospective propensity-matched analysis of MV operations between January 2005 and December 2015. Results Among 1357 patients, 496 underwent CS and 861 MIS. Matching resulted in 422 patients per group. The procedure time was longer with MIS than CS (192 vs. 185 min; p  = 0.002) as was cardiopulmonary bypass time (133 vs. 101 min; p  < 0.001) and X-clamp time (80 vs. 71 min; p  < 0.001). ‘Short-term’ successful valve repair was higher with MIS (96.0% vs. 76.0%, p  < 0.001). Length of hospital stay was shorter in MIS than CS patients (10 vs. 11 days; p  = 0.001). There was no difference in the overall 30-day mortality rate. Cardiovascular death was lower after MIS (1.2%) compared with CS (3.8%; OR 0.30; 95%CI 0.11–0.84). The difference did not remain significant after adjustment for procedural differences (aOR 0.40; 95%CI 0.13–1.25). Pacemaker was required less often after MIS (3.3%) than CS (11.2%; aOR 0.31; 95%CI 0.16–0.61), and acute renal failure was less common (2.1% vs. 11.9%; aOR 0.22; 95%CI 0.10–0.48). There were no significant differences with respect to rates of stroke, myocardial infarction or repeat MV surgery. The 7-year survival rate was significantly better after MIS (88.5%) than CS (74.8%; aHR 0.44, 95%CI 0.31–0.64). Conclusion This study demonstrates that good results for MV surgery can be obtained with MIS, achieving a high MV repair rate, low peri-procedural morbidity and mortality, and improved long-term survival.