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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.

Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection. We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure. During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment. When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.

Background Sternotomy and lateral thoracotomy are required infrequently to remove an intrathoracic goitre (ITG). As few studies have explored the need for an extracervical approach (ECA), the aim of this study was to examine this in a large cohort of patients. Methods A prospective database of all patients who had surgery for ITG between 2004 and 2016 was interrogated. Patient demographics, preoperative characteristics and type of operation were analysed to identify factors associated with an ECA. Results Of 237 patients who had surgery for ITG, 29 (12·2 per cent) required an ECA. ITGs below the aortic arch (odds ratio (OR) 10·84; P = 0·004), those with an iceberg shape (OR 59·30; P < 0·001) and revisional surgery (OR 4·83; P = 0·022) were significant preoperative predictors of an ECA. Conclusion The extent of intrathoracic extension in relation to the aortic arch, iceberg goitre shape and revisional surgery were independent risk factors for ECA. Careful preoperative assessment should take these factors into consideration when determining the optimal surgical approach to ITG. The aim of this study was to explore the need for an extracervical approach (ECA) to remove an intrathoracic goitre (ITG) analysing a large prospective cohort of patients. The extent of intrathoracic extension in relation to the aortic arch, iceberg goitre shape and revision surgery were independent risk factors for ECA. Careful preoperative assessment taking these factors into consideration is recommended for optimal surgical management of ITGs. Useful factors to determine approach

Purpose To investigate whether tracheostomy increases the risk of sternal wound infection (SWI) post cardiac surgery. Methods All patients undergoing cardiac surgery via median sternotomy from September 1997 to October 2010 were included in this retrospective observational study. Primary exposure was tracheostomy performed during admission to the cardiac surgical intensive care unit. The primary outcome was SWI during hospital admission. Multivariable logistic regression was used to determine if tracheostomy was an independent predictor of SWI. Restriction and propensity score analyses were then used to assess if tracheostomy is a causal risk factor for SWI. Results Four hundred and eleven of 18,845 patients (2.2%) were treated with tracheostomy. Incidences of SWI in tracheostomy and non-tracheostomy groups were 19.5% (80/411) and 0.8% (154/18,434), respectively. Using multivariable logistic regression analysis, tracheostomy was found to be an independent predictor of SWI (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.9 to 4.2). In an analysis restricted to respiratory failure patients, tracheostomy was associated with sternal wound infection (OR 3.4; 95% CI 2.4 to 4.9). When the analysis was stratified by the risk of receiving tracheostomy as represented by propensity score (PS), 46 patients (12%) in the intermediate risk category (PS 0.2-0.4) had SWIs (adjusted OR 2.97; 95% CI 1.6 to 5.6), and 52 patients (14%) in the highest risk category (PS > 0.4) had SWIs (OR 1.52; 95% CI 0.85 to 2.87). Discussion Our single-centre observational study of cardiac surgery patients found tracheostomy to be an independent risk factor for SWI. Our analysis showed a robust association when restricted to patients with respiratory failure and after the population was stratified by the propensity to have a tracheostomy.

Background The objectives of this study were to evaluate the feasibility of video-assisted thoracoscopic (VATS) thymoma resection and to analyze the factors contributing to a successful perioperative period. Methods Fifty-one patients with thymoma underwent VATS with the aim of thymoma resection. Four patients underwent minithoracotomy [due to technical difficulties, including small chest cavity, high body mass index (BMI), and disintegration of the capsule] and three patients underwent sternotomy (due to invasion of major vascular structures). The seven open-converted patients and seven other patients who underwent complete VATS thymoma resection but experienced prolonged hospital stay (≥7 days) formed Group B ( n  = 14), namely, the unsuccessful group, while successful VATS thymoma resection patients formed Group A ( n  = 37). The groups were compared with each other in terms of the characteristics of patients, tumors, and perioperative period. Results Patients’ characteristics, tumor size, WHO histologic type, and complications were similar in both Groups A and B ( p  > 0.05). Patients with Masaoka stage I and II thymomas were significantly more frequent in Group A ( p  < 0.01). Tumor size was a statistically insignificant variable for the determination of a successful VATS thymoma resection ( p  = 0.3). Masaoka stage and the size of the thymoma did not have any correlation with each other ( p  > 0.05). Conclusions The size of the thymoma was not observed to be correlated with Masaoka stage and it was not noted to be an important factor in successful VATS thymoma resection. A higher Masaoka stage (III and IVa) was found to be the only variable that predicted unsuccessful situations. Thus, Masaoka stage, rather than the size of the thymoma, should be the main concern for the surgeon.

Background Aortic valve replacement is one of the most common cardiac surgical procedures performed worldwide. Conventional aortic valve replacement surgery is performed via a median sternotomy; the sternum is divided completely from the sternal notch to the xiphisternum. Minimally invasive aortic valve replacement, using a new technique called manubrium-limited ministernotomy, divides only the manubrium from the sternal notch to 1 cm below the manubrio-sternal junction. More than one third of patients undergoing conventional sternotomy develop clinically significant bleeding requiring post-operative red blood cell transfusion. Case series data suggest a potentially clinically significant difference in red blood cell transfusion requirements between the two techniques. Given the implications for National Health Service resources and patient outcomes, a definitive trial is needed. Methods/design This is a single-centre, single-blind, randomised controlled trial comparing aortic valve replacement surgery using manubrium-limited ministernotomy (intervention) and conventional median sternotomy (usual care). Two hundred and seventy patients will be randomised in a 1:1 ratio between the intervention and control arms, stratified by baseline logistic EuroSCORE and haemoglobin value. Patients will be followed for 12 weeks from discharge following their index operation. The primary outcome is the proportion of patients who receive a red blood cell transfusion post-operatively within 7 days of surgery. Secondary outcomes include red blood cell and blood product transfusions, blood loss, re-operation rates, sternal wound pain, quality of life, markers of inflammatory response, hospital discharge, health care utilisation, cost and cost effectiveness and adverse events. Discussion This is the first trial to examine aortic valve replacement via manubrium-limited ministernotomy versus conventional sternotomy when comparing red blood cell transfusion rates following surgery. Surgical trials present significant challenges; strengths of this trial include a rigorous research design, standardised surgery performed by experienced consultant cardiothoracic surgeons, an agreed anaesthetic regimen, patient blinding and consultant-led patient recruitment. The MAVRIC trial will demonstrate that complex surgical trials can be delivered to exemplary standards and provide the community with the knowledge required to inform future care for patients requiring aortic valve replacement surgery. Trial registration International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN29567910 . Registered on 3 February 2014.

Introduction Heart surgery is associated with a sternotomy in most patients. Low serum calcidiol level below 80 nmol/l carries the risk of bone loss as a risk factor in sternotomy healing. Objectives The primary objective was to compare postoperative complications of sternotomy healing in two groups of patients treated with cholecalciferol or placebo. Secondary objectives were focused on the degree of sternal healing, length of hospitalization, number of days spent in ICU and mechanical ventilation, and number of repeated hospitalizations for sternotomy complications. Methodology Monocentric, randomized, double-blind, placebo-controlled, prospective study was conducted from September 2016 to December 2020 at Na Homolce Hospital. Of the 216 originally recruited and randomized subjects, 141 completed the study. Seventy-two subjects were enrolled in the cholecalciferol arm, and sixty-nine subjects in the placebo arm. The detailed methodology has been published previously. The results are presented as a comparison between two groups: calcidiol above 80 nmol/l (saturated subjects) and the calcidiol lower or equal to 80 nmol/l (unsaturated subjects). Results Statistics include 141 subjects. After a 6-month follow-up, CT imaging and calcidiol levels were performed. Primary objective: postoperative complications in sternotomy were not among the population under or above 80 nmol/l statistical difference ( p  = 0.907). Secondary objectives: monitored parameters did not differ between individual arms. But the key was the state of saturation with calcidiol (> 80 nmol/l), which was associated with a significantly lower risk of complete non-healed sternotomy ( p  = 0.008). Conclusion Optimal calcidiol level (> 80 nmol/l) indicates a positive trend towards greater sternal healing. Cholecalciferol oral administration can be considered as a safe method how to achieve the required calcidiol concentration. Trial registration EU Clinical Trials Register, EUDRA CT No: 2016–002606-39.

Background Video-assisted thoracoscopic surgery (VATS) for a relatively large mediastinal tumor (5.0–10.0 cm) remains controversial. In addition, few studies have focused on comparing different surgical approaches for large mediastinal tumors. Therefore, this study aimed to compare the short-term outcomes between subxiphoid approach VATS, intercostal approach VATS, and traditional sternotomy for large-sized anterior mediastinal tumors. Methods The study consecutively enrolled 159 patients with large-sized anterior mediastinal tumors (5.0–10.0 cm) who received surgery in our hospital between January 2018 and July 2022 (subxiphoid approach VATS: 52 patients, intercostal approach VATS: 70 patients, traditional sternotomy: 37 patients). We analyzed the clinical baseline data, intraoperative and postoperative outcomes, and postoperative complications of all patients. Then the patients were further divided into two groups according to whether there was a peripheral organ (such as pericardium, lung, or left innominate vein) invasion: group A, invasion of the surrounding organ, and group B, no invasion of the surrounding organ. Intraoperative and postoperative outcomes and postoperative complications were also analyzed in group A and group B, respectively. Results In all patients, there were significant differences in blood loss (subxiphoid approach: 33.1 ± 46.0 ml, intercostal approach: 36.9 ± 44.1 ml, sternotomy: 113.0 ± 84.9 ml, P  < 0.001) and duration of postoperative oral analgesics (subxiphoid approach: 3.4 ± 0.9 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.5 ± 1.5 d, P  = 0.002) among the three methods. In group A, there was a significant difference in blood loss (subxiphoid approach: 50.0 ± 67.7 ml, intercostal approach: 90.0 ± 66.6 ml, sternotomy: 157.9 ± 90.2 ml, P  < 0.001) among the three methods. In group B, there were significant differences in the duration of postoperative oral analgesics (subxiphoid approach: 3.2 ± 0.8 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.2 ± 1.1 d, P  < 0.05) and blood loss (subxiphoid approach: 22.5 ± 19.3 ml, intercostal approach: 31.9 ± 38.5 ml, sternotomy: 65.6 ± 44.9 ml, P  < 0.001) between the three methods. There were no significant differences in the postoperative complications. Conclusions VATS is an effective, minimally invasive, and safe procedure for large-sized anterior mediastinal tumors (5.0–10.0 cm) without an invasion of the surrounding organs, and maybe a feasible and secure method for large-sized anterior mediastinal tumors with an invasion of the surrounding organ (such as the pericardium, lung, or left innominate vein). Subxiphoid approach VATS is a less invasive procedure than intercostal approach VATS and traditional sternotomy due to its reduced blood loss and postoperative pain.

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.