Sternotomy – ABC CARDIOL

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Neurovascular Lesion Caused by Non-Lethal Projectile in Cervical Region

Milton Sérgio Bohatch Júnior et al. Amanda Fernandes Vidal da Silva Agnaldo José Graciano

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IJCS

Editorial

Pain after Cardiac Surgery

Tirone E. David

Most cardiac operations are performed via median sternotomy and cardiopulmonary bypass. Both thoracic incision and cardiopulmonary bypass cause major disturbances in the homeostasis of the patient. Disruption of the tissues by the incision initiates an immediate neurological reaction perceived as pain and an intense biochemical and cellular response to repair the wound. Cardiopulmonary bypass causes far more serious systemic changes in homeostasis than pain, and that is probably the main reason why cardiac surgery is behind other surgical specialties in the development of minimally invasive procedures. Pain associated with surgical incision is largely self-limited and resolves with time and, luckily, so do the changes caused by cardiopulmonary bypass. Obviously, surgical incisions that cause less tissue damage are associated with lower degrees of pain and metabolic disturbance than larger and more traumatic incisions.

In this issue of the International Journal of Cardiovascular Sciences, Silva and colleagues, from the University of Fortaleza, Brazil, report a comparative study on postoperative pain following conventional median sternotomy and right mini-thoracotomy. The study has limitations because of the sample size (there were only 17 patients in each arm), the endpoint of the study was largely subjective, and patients were not randomized. However, as one would expect, both groups of patients complained of pain in the first three days but fewer patients with mini-thoracotomy complained of pain by the seventh postoperative day. In addition, mini-thoracotomy was associated with pain of lower intensity, fewer sites, and shorter duration than median sternotomy.

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IJCS

Original Article

Minimally Invasive Cardiac Surgery versus Sternotomy – Pain Investigation

Juliana Fernandes Silva et al. Marcela Paula Cavalcante Roger Benevides Montenegro Romulo Lira … Emanuel Carvalho Mel Josue Viana Castro

Abstract

Background:

Treatment of postoperative (PO) pain is essential after surgery, as it contributes to a faster rehabilitation. Assessment of PO pain after minimally invasive (MI) surgery has not been regularly addressed, especially when compared with median sternotomy (MS).

Objective:

This study aims to evaluate the intensity of thoracic pain in the PO period in patients subjected to MI surgery and MS.

Methods:

This study compared the intensity of thoracic pain in 34 patients subjected to minimally invasive (MI; n = 17) and median sternotomy (MS; n = 17) from June 2015 to June 2016. The intensity and sites of pain in the PO period, assessed using the visual numeric pain scale, and the need for pain medications were analyzed using the Student’s t-test and the z test, with confidence level of 95% (p < 0.05).

Results:

Almost all patients reported pain on the third PO day (MS = 94.1% and MI = 88.2%; p = 0.5410). On the seventh PO day, there were significantly more patients free of pain in the group of patients subjected to the MI procedure (MS = 94.1% and MI = 64.7%; p = 0.0341). also, these patients reported fewer pain sites (3^rd PO day: MS = 3.2 ± 1.5; MI = 1.5 ± 1.2; p = 0.001; 7^th PO day: MS = 3.1 ± 1.4; MI = 0.9 ± 0.9; p = 0.000). Patients undergoing MS reported higher pain intensity and longer lasting pain (3^rd PO: MS = 4.8 ± 2.2; MI = 3.0 ± 1.6; 7^th PO: MS = 5.3 ± 2.0; MI = 1.2 ± 1.3; p = 0.001), with no difference in pain intensity between the third and the seventh PO days (p = 0.4931). In addition, patients subjected to MI procedure had a significant decrease in pain intensity from the third to the seventh PO days (p = 0.001).

Conclusion:

According to these results, we concluded that a MI procedure leads to lower intensity of pain in the PO period (from the third PO day on) when compared to a MS; also, patients undergoing MI patients reported fewer pain sites.

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ABC

Artigo Original

Mitral valve and atrial septal defect surgery: minimally invasive or sternotomy approach

Josué V. Castro Neto et al. Emanuel Melo Juliana Fernandes Regina Gomes … Caroline Freitas João Machado Francisco Martins Aloísio Barbosa Bernardo Oliveira Cesar Gondim

BACKGROUND: To decrease the surgical trauma in heart procedures, minimally invasive (MI) techniques were alternatively introduced. OBJECTIVE: To compare MI surgical access with median sternotomy (MS) for the treatment of mitral valve (MV) disease and atrial septal defect (ASD). METHODS: Forty patients underwent surgery for correction of MV disease or ASD. Patients were divided into group A (GA) (n=20), access by right minithoracotomy and video-assistance; and group B (GB) (n=20), access by full MS. Aortic cross-clamp and cardiopulmonary bypass time, intensive care unit (ICU) time, hospital stay and morbidity were compared in this prospective study . RESULTS: Fifteen patients were submitted to MV procedures and five to ASD corrections in each group. There were 9 mitral replacements (7 bioprostetic and 2 mechanical) and 6 repairs in GA, and 10 (all bioprostetic) and five in GB. The mean aortic cross-clamp and cardiopulmonary bypass time, in minutes, were 65.1 ± 29.3 in GA and 50.2 ± 21.4 in GB (p=0.074); and 91.8±35 in GA and 63.7±27.3 in GB ( p=0.008). The mean ICU time, in hours, were 51.7 ± 16.3 in GA and 55.8±17.5 in GB (p=0.45). The in hospital stay, in days, were 5.2 ± 1 in GA and 6.4±1.5 in GB (p=0.009). CONCLUSION: MI access for correction of the MV disease and ASD implicated in a longer cardiopulmonary bypass time for finalization of the main procedure, nevertheless it didn´t affect patient’s recuperation. MI treated patients were discharged earlier than sternotomy treated patients.

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Artigo Original

Ministernotomy in myocardial revascularization preserves postoperative pulmonary function

Solange Guizilini et al. Douglas W. Bolzan Sonia M. Faresin Francisco A. Alves Walter J. Gomes

BACKGROUND: In coronary artery bypass graft (CABG) surgery, the need to perform a midsternotomy has been considered a factor for the decrease in postoperative pulmonary function. OBJECTIVE: To prospectively evaluate early postoperative (PO) pulmonary function in patients submitted to off-pump CABG, comparing the conventional midsternotomy with the ministernotomy approach. METHODS: A total of 18 patients were evaluated and assigned to the two groups: Group Conventional Midsternotomy (CMS, n=10) and Group Ministernotomy (MS, n=8). Spirometric results of the forced vital capacity (FVC) and the Forced Expiratory Volume in one second (FEV1) were obtained on the 1st, 3rd and 5th PO days and the arterial gasometry was obtained before and on the 1st PO day. The pulmonary shunt percentage and the pain score were also assessed. RESULTS: When compared in terms of percentage of the preoperative value, the FVC was higher in the MS group than in the CMS group on the 1st, 3rd and 5th PO days (p<0.001). Similar results were obtained for FEV1. The recovery of the FVC between the 1st and the 5th PO days was higher in the MS than in the CMS group (p=0,043). The PaO2 decreased on the 1st PO day in both groups (p<0.05), with a higher decrease in the CMS group (p=0.002). The shunt increased in the two groups on the 1st PO day (p<0.05); however, it was lower in the MS group (p=0.02). The reported pain score was lower and the duration of the hospital stay was shorter in the MS group. CONCLUSION: Patients submitted to CABG by MS present better preservation and recovery of pulmonary function than those submitted to CMS.

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ABC

Artigo Original

Partial sternotomy in H. A new approach for cardiac surgery

Danton R. Loures et al. Leonardo A. Mulinari André L. Tyszka Edison Ribeiro … Roberto G. Carvalho Rui Almeida

PURPOSE: To present our results with the minimally invasive thoracotomy (MIT) in patients with valve disease and to describe a new type of thoracotomy. METHODS: Twenty-five patients with valve disease as the major cardiac problem were operated during a five month period. Two types of incisions were used: one in an inverted-T fashion and another in a H fashion. Fourteen patients were submitted to an inverted-T incision and eleven to a H incision. In 24% of the patients reoperation was being performed. RESULTS: The incisions ranged from 7.5 to 11cm (mean 9.1cm), mean ICU stay was 31h and hospital stay 4.8 days. In all but one patient the operation could be adequately in performed through the MIT, in only one patient total sternotomy had to be performed. CONCLUSION: The MIT may have some advantages such as, better aesthetic results, less pain and more sternal stability. These factors may improve early extubation and decrease hospital stay. The H type incision allows an adequate exposition of the most central part of the chest and all heart valves with adequate exposure. This technique led to no complications during reoperations and we believe it to be as safe as the total sternotomy.

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Original Article

Mini-sternotomy for the treatment of aortic valve lesions

Altamiro Ribeiro Dias et al. Ricardo Ribeiro Dias Fábio Gaiotto José Lima O. Júnior … Filinto M.C.N. Cerqueira Max Grinberg Roney Sampaio Paulo de Lara Lavitola Nelson Elias Flávio Tarasoutchi Luiz F. Cardoso Noedir A. G. Stolf

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous ¼-inch cannula, and the patients were maintained in Trendelemburg’s position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided morecomfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.

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