Search

Objectives: Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy., Methods: We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4., Results: Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001)., Conclusions: Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Reoperative sternotomy is associated with poor outcomes after cardiac surgery. We aimed to investigate the impact of reoperative sternotomy on the outcomes after aortic root replacement., Methods: All patients who underwent aortic root replacement from January 2011 to June 2020 were identified using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. We compared outcomes between patients who underwent first-time aortic root replacement with those with a history of sternotomy undergoing reoperative sternotomy aortic root replacement using propensity score matching. Subgroup analysis was performed among the reoperative sternotomy aortic root replacement group., Results: A total of 56,447 patients underwent aortic root replacement. Among them, 14,935 (26.5%) underwent reoperative sternotomy aortic root replacement. The annual incidence of reoperative sternotomy aortic root replacement increased from 542 in 2011 to 2300 in 2019. Aneurysm and dissection were more frequently observed in the first-time aortic root replacement group, whereas infective endocarditis was more common in the reoperative sternotomy aortic root replacement group. Propensity score matching yielded 9568 pairs in each group. Cardiopulmonary bypass time was longer in the reoperative sternotomy aortic root replacement group (215 vs 179 minutes, standardized mean difference = 0.43). Operative mortality was higher in the reoperative sternotomy aortic root replacement group (10.8% vs 6.2%, standardized mean difference = 0.17). In the subgroup analysis, logistic regression demonstrated that individual patient repetition of (second or more resternotomy) surgery and annual institutional volume of aortic root replacement were independently associated with operative mortality., Conclusions: The incidence of reoperative sternotomy aortic root replacement might have increased over time. Reoperative sternotomy is a significant risk factor for morbidity and mortality in aortic root replacement. Referral to high-volume aortic centers should be considered in patients undergoing reoperative sternotomy aortic root replacement., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence., Methods: A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates., Results: One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score., Conclusions: This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Our objective was to compare outcomes after left ventricular assist device implantation performed via median sternotomy or lateral thoracotomy., Methods: We retrospectively analyzed 222 adult patients with the HeartMate3 (Abbott Lab) left ventricular assist device implanted between November 2014 and November 2021. Outcomes stratified by surgical approach were evaluated in propensity score-matched groups. The primary outcome was 1-year survival. Secondary outcomes included in-hospital morbidity and mortality, readmissions, and significant valvular regurgitation., Results: Our cohort consisted of 60 patients (27%) who underwent lateral thoracotomy and 162 patients (73%) who underwent median sternotomy. Propensity score matching compared 45 patients who underwent lateral thoracotomy with 68 patients who underwent median sternotomy. There were no differences in intensive care unit or hospital stay duration (median, 10 vs 11 days, P = .58; 46 vs 40 days, P = .279), time to extubation (median, 2 days, P = .627), vasoactive-inotropic scores at intensive care unit arrival (18.20 vs 16.60, P = .654), or in-hospital mortality (2 [5%] vs 4 [6.1%] patients, P = 1). One-year survival (95.56% vs 90.61%, P = .48) and all-cause hospital readmission rate (Gray's test: P = .532) were also comparable. Patients who underwent lateral thoracotomy had significantly less early right ventricular failure (24.4% vs 53.7%, P = .004), although they had more follow-up tricuspid regurgitation (17.6% vs 0%, P = .030) and volume overload readmissions (Gray's test: P = .0005)., Conclusions: Our data suggest that lateral thoracotomy is a safe although not necessarily superior alternative to median sternotomy for HeartMate 3 implantation in the perioperative and postoperative periods, because it precludes concomitant tricuspid valve repairs and may be associated with increased risk of late tricuspid regurgitation and volume overload readmissions., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Regaining and maintaining sternal stability are key to recovery after cardiac surgery and resuming baseline quality of life. Montage (ABYRX) is a moldable, calcium phosphate-based putty that adheres to bleeding bone, hardens after application, and is resorbed and replaced with bone during the remodeling process. We evaluate the feasibility, safety, and efficacy of enhanced sternal closure with this novel putty to accelerate recovery in patients after sternotomy., Methods: A single-center, single-blinded, randomized controlled trial was performed (NCT03365843). Patients undergoing elective cardiac surgery via sternotomy received sternal closure with either Montage bone putty and wire cerclage (enhanced sternal closure; n = 33) or wire cerclage alone (control; n = 27). Standardized patient-reported outcomes assessed health-related quality of life (EQ-5D Index) and physical disability (Health Assessment Questionnaire). A Likert-type 11-point scale quantified pain. Spirometry assessed respiratory function. Patients reached 6-week follow-up, with 1-year follow-up for safety end points., Results: There were no device-related adverse events. Enhanced sternal closure improved physical functional recovery (reduced Healthcare Index and Quality) and quality of life (increased EQ-5D Index) at day 5/discharge, week 2, and week 4. Enhanced sternal closure reduced incisional pain while resting, breathing, sleeping, and walking at day 5/discharge. Enhanced sternal closure reduced chest wall and back pain at day 3 and day 5 discharge. A higher proportion of patients with enhanced sternal closure recovered to 60% of their baseline forced vital capacity by day 5/discharge. Enhanced sternal closure shortened hospital stay., Conclusions: Enhanced sternal closure improves and accelerates postoperative recovery compared with conventional wire closure. Earlier discharge may provide substantial cost benefits for the healthcare system., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest., Methods: From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect., Results: Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2)., Conclusions: Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy., (Copyright © 2021. Published by Elsevier Inc.)

Background: Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach., Methods: Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation., Results: The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77)., Conclusions: The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Partial upper sternotomy (mini-ER) can be used in some adult cardiac surgeries but is seldom performed in the treatment of acute type A aortic dissection (AAAD). This study aimed to assess the feasibility and short-term outcomes of complete stent-graft replacement of the arch with triple-branched stent graft for AAAD through a mini-ER., Methods: From 2015 to 2018, 254 patients with AAAD underwent complete stent-graft replacement of the arch with a triple-branched stent graft. Replacement was performed with conventional full sternotomy (con-ER) in 142 patients and with mini-ER in the other 112 patients. Using propensity score matching, the clinical data were compared between 100 patients in the mini-ER group and 100 patients in the con-ER group., Results: After propensity score matching, there were no significant between-group differences in aortic cross-clamp time, cardiopulmonary bypass time, or total operative time. The amount of mediastinal drainage and number of red blood cell units were significantly lower in the mini-ER group compared with the con-ER group (P < .001). The intubation time was significantly shorter in the mini-ER group (P < .001). The treatment costs were also lower in the mini-ER group (P < .001). There were no significant between-group differences in 30-day mortality (9% vs 8%; P > .99) or postoperative complications., Conclusions: This study shows that extensive repair of AAAD through a mini-ER is feasible. It was superior to con-ER in terms of blood loss, postoperative ventilation time, and treatment costs., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases., Objective: To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications., Methods: Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors., Results: 1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis., Conclusion: Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection., Competing Interests: Declaration of Competing Interest No conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Redo sternotomy in patients with arterial cardiac structures adherent to the sternum carries a risk of catastrophic bleeding. In some of those cases, particularly if they have undergone multiple previous operations, deep hypothermic circulatory arrest alone may not provide sufficient time for a controlled dissection., Methods: We present a series of 6 cases at risk for exsanguination during sternal re-entry successfully reoperated using percutaneous cardioplegic cardiac arrest induced before completed sternal re-entry to avoid or minimize the hypothermic circulatory arrest time., Results: All patients survived their complex operations., Conclusions: Percutaneous cardioplegic arrest allows safer repeat sternotomy in patients with arterial cardiac structures adherent to the sternum., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures., Methods: Between March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time., Results: There were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%., Conclusions: Excellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme., Methods: Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients., Results: Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P < .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively., Conclusions: Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Proximal aortic repair (AoR) in the setting of previous sternotomy may be associated with greater risk than primary repair. Our objective was to determine whether redo sternotomy increases the risk of adverse outcomes following proximal aortic surgery., Methods: We reviewed all proximal AoRs from 1991 to 2014. Outcomes were compared between first-time AoR (non-redo = 1305) and redo AoRs, which were further classified into 3 categories: (1) previous acute type A aortic dissection (AAD) repair (redo-AAD = 146, 8.3%); (2) previous proximal aneurysm repair (redo-aneurysm = 165, 9.4%); and (3) previous cardiac (non-aortic) sternotomy (redo-cardiac = 145, 8.2%). Data were analyzed by contingency tables and multiple regression., Results: In total, 456 of 1761 (25.9%) proximal AoRs had redo sternotomy. Aortic redos (redo-AAD and redo-cardiac) had significantly more connective tissue disorders (P < .001). On presentation, AAD was least common in aortic redos followed by cardiac redos (redo-cardiac) versus non-redos (5% vs 28% vs 31%, P < .001). At reoperation, 190 underwent ascending + hemiarch (21% redo-AAD, 50% redo-aneurysm, 53% redo-cardiac), 140 total arch (64% redo-AAD, 15% redo-aneurysm, 15% redo-cardiac), 110 elephant trunk (52% redo-AAD, 12% redo-aneurysm, 11% redo-cardiac), 159 AVR (36% redo-AAD, 42% redo-aneurysm, 25% redo-cardiac), and 100 aortic root (34% redo-AAD, 22% redo-aneurysm, 10% redo-cardiac). Except for pulmonary, redo sternotomy did not increase risk of postoperative complications. Thirty-day mortality after redo sternotomy was 14%-the greatest among cardiac redos. Over a median follow-up of 13 years, non-redos had significantly greater long-term survival (P < .001). Coronary artery disease was a significant predictor of mortality (P < .001). After adjustment for coronary artery disease, cardiac redos had the greatest long-term mortality risk (hazard ratio, 1.43, P < .005). Previous AoR did not significantly add risk above redo sternotomy alone (P = .734)., Conclusions: Redo sternotomy is associated with increased risk for short- and long-term mortality after proximal aortic repair. Despite need for extensive repair, previous proximal aortic (for aneurysm or AAD) repair did not add further risk above that attributable to redo sternotomy., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare safety and clinical effectiveness of negative-pressure wound therapy (NPWT) with traditional wound therapy for managing noninfected open chests with delayed sternal closure after cardiac surgery., Methods: From January 2000 to July 2015, 452 of 47,325 patients who underwent full sternotomy left the operating room with a noninfected open chest (0.96%), managed using NPWT in 214-with frequency of use rapidly increasing to near 100%-and traditionally in 238. Predominant indications for open-chest management were uncontrolled coagulopathy or hemodynamic compromise on attempted chest closure. Weighted propensity-score matching was used to assess in-hospital complications and time-related survival., Results: NPWT and traditionally managed patients had similar high-risk preoperative profiles. Most underwent reoperations (63% of the NPWT group and 57% of the traditional group), and 21% versus 25% were emergency procedures. Reexplorations for bleeding were less common with NPWT versus traditional wound therapy (n = 63 [29%] vs 104 [44%], P = .002). Median duration of open-chest to definitive sternal closure was 3.5 days for NPWT versus 3.1 for traditionally managed patients (P[log rank] = .07). Seven patients (3.3%) were converted from NPWT to traditional therapy because of hemodynamic intolerance and 6 (2.5%) from traditional to NPWT. No NPWT-related cardiovascular injuries occurred. Among matched patients, NPWT was associated with better early survival (61% vs 44% at 6 months; P = .02)., Conclusions: NPWT is safe and effective for managing noninfected open chests after cardiac surgery. By facilitating open-chest management and potentially improving outcomes, it has become our therapy of choice and perhaps has lowered our threshold for leaving the chest open after cardiac surgery., (Copyright © 2018. Published by Elsevier Inc.)

Objective: Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR., Methods: This pragmatic, open-label, parallel randomized controlled trial (RCT) compared MS with FS for first-time isolated AVR in 2 United Kingdom National Health Service hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analyzed in the intent-to-treat population., Results: In this RCT, 222 patients were recruited and randomized (n = 118 in the MS group; n = 104 in the FS group). Compared with the FS group, the MS group had a longer hospital length of stay (mean, 9.5 days vs 8.6 days) and took longer to achieve fitness for discharge home (mean, 8.5 days vs 7.5 days). Adjusting for valve type, sex, and surgeon, hazard ratios (HRs) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR, 0.874; 95% confidence interval [CI], 0.668-1.143; P = .3246) or time to fitness for discharge (HR, 0.907; 95% CI, 0.688-1.197; P value = .4914). During a mean follow-up of 760 days (745 days for the MS group and 777 days for the FS group), 12 patients (10%) in the MS group and 7 patients (7%) in the FS group died (HR, 1.871; 95% CI, 0.723-4.844; P = .1966). Average extra cost for MS was £1714 during the first 12 months after AVR., Conclusions: Compared with FS for AVR, MS did not result in shorter hospital stay, faster recovery, or improved survival and was not cost-effective. The MS approach is not superior to FS for performing AVR., (Copyright © 2018 The American Association for Thoracic Surgery. All rights reserved.)

Objectives: Although transcatheter aortic valve implantation was the treatment of choice in inoperable and high-risk patients, the effect of transcatheter aortic valve implantation relative to conventional aortic valve replacement via ministernotomy in patients with moderate surgical risk remains unclear., Methods: We consecutively enrolled patients who underwent minimally invasive aortic valve replacements via ministernotomy (n = 1929), transapical (n = 607), and transfemoral (n = 1273) aortic valve implantations from a single center during the period from July 2009 to July 2017. Of those, we conducted a 1:1:1 propensity score matching according to 23 preoperative risk factors., Results: We were able to find 177 triplets (n = 531). The median European System for Cardiac Operative Risk Evaluation II was 3.0% versus 3.4% versus 2.9%, and Society of Thoracic Surgeons Predicted Risk of Mortality was 3.2% versus 3.6% versus 3.4%, respectively. According to the Valve Academic Research Consortium 2 criteria, there were no significant periprocedural differences regarding 30-day mortality (2.3% minimally invasive aortic valve replacement vs 4.5% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .34), stroke (1.1% minimally invasive aortic valve replacement vs 0.6% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .84), or myocardial infarction (0.6% minimally invasive aortic valve replacement vs 0.0% transapical transcatheter aortic valve implantation vs 0.0% transfemoral transcatheter aortic valve implantation, P = .83). Both intensive care and hospitalization times were significantly longer in the transapical group. Regarding midterm survival, transapical transcatheter aortic valve implantation was associated with a tendency toward a less favorable outcome (hazard ratio, 1.48; 95% confidence interval, 0.95-2.31; P = .17) compared with minimally invasive aortic valve replacement., Conclusions: In this real-world propensity score-matched minimally invasive aortic valve replacement, transapical transcatheter aortic valve implantation, transfemoral transcatheter aortic valve implantation cohort of intermediate-risk patients, early mortality was not significantly different, whereas the rates of periprocedural complications were different depending on the approach. During follow-up, there was a tendency in the transapical transcatheter aortic valve implantation group toward a less favorable survival outcome, although there was no significant difference among the 3 groups., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Midline sternotomy remains the most common access incision for cardiac operations. Traditionally, the sternum is closed with stainless steel wires. Wires are well known to stretch and break, however, leading to pain, nonunion, and potential deep sternal wound infection. We hypothesized that biocompatible plastic cable ties would achieve a more rigid sternal fixation, reducing postoperative pain and analgesia requirements., Methods: A prospective, randomized study compared the ZIPFIX (De Puy Synthes, West Chester, Pa) sternal closure system (n = 58) with standard stainless steel wires (n = 60). Primary outcomes were pain and analgesia requirements in the early postoperative period. Secondary outcome was sternal movement, as assessed by ultrasound at the postoperative follow-up visit., Results: Groups were well matched in demographic and operative variables. There were no significant differences between groups in postoperative pain, analgesia, or early ventilatory requirements. Patients in the ZIPFIX group had significantly more movement in the sternum and manubrium on ultrasound at 4 weeks., Conclusions: ZIPFIX sternal cable ties provide reliable closure but no demonstrable benefit in this study in pain or analgesic requirements relative to standard wire closure after median sternotomy., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate clinical outcomes of different approaches to patients with proximal descending thoracic aneurysm (DTA) involving the distal arch., Methods: From January 2002 to December 2016, 229 consecutive patients with proximal descending aorta aneurysm involving the distal arch underwent surgery using different approaches: total arch and DTA replacement via sternotomy (TAR group; n = 98), hemiarch and DTA replacement via thoracotomy (DTR group; n = 84), or hybrid arch repair (HAR group; n = 47). We retrospectively evaluated the outcomes of the 3 groups with a mean follow-up duration of 60.2 months., Results: The in-hospital mortality rate was 3.1% (3/98) in the TAR group, 11.9% (10/84) in the DTR group, and 4.3% (2/47) in the HAR group (P = .04). The TAR group had a lower incidence of stroke (3.1%, 3/98) compared with the DTR (13.1%, 11/84) and HAR (10.6%, 5/47) groups (P = .03). The overall survival rate at 10 years was 82.8% ± 5.6% for the TAR group, 61.0% ± 8.6% for the DTR group, and 55.9% ± 9.0% for the HAR group (vs DTR [P = .03] and HAR [P < .01]). The freedom from composite of aortic events at 10 years was 75.6% ± 8.1% in the TAR group, 43.6% ± 14.9% in the DTR group, and 31.1% ± 11.5% in the HAR group (P < .01)., Conclusions: The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and long-term survival compared with the thoracotomy or hybrid approaches. This study suggests that the sternotomy approach is the superior option for patients with proximal descending aneurysm involving the distal arch., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Mediastinitis is a serious complication of heart surgery. In this study, we developed a bedside risk score for poststernotomy mediastinitis., Methods: Data were prospectively collected from 4625 patients admitted to our intensive care unit after heart surgery (January 2005-June 2011). Mediastinitis was defined according to Centers for Disease Control and Prevention criteria. A logistic model was constructed in a randomly selected subgroup of 2618 patients and validated in a second cohort of 1352, as well as in a prospective cohort of 2615 (June 2011-December 2015). Model discriminatory power was assessed according to the area under the receiver operating characteristic curve (AUROC). The β coefficients of the model were used to define 3 levels of mediastinitis risk as a score designated Med-Score 24. Its performance to predict mediastinitis was compared with that of the logistic EuroSCORE and Society of Thoracic Surgeons score., Results: Ninety-four (2.36%) patients developed mediastinitis. The risk factors identified as predictive of mediastinitis (AUROC 0.80) were 4 preoperative variables (age >70 years, chronic obstructive lung disease, obesity, and antiplatelet therapy) and 3 perioperative variables (prolonged ischemia, emergency reoperation, and prolonged intubation). AUROCs for the Society of Thoracic Surgeons score and logistic EuroSCORE were 0.63 and 0.55, respectively, both differing significantly from the area calculated for Med-Score 24 (P < .001)., Conclusions: The score developed showed excellent predictive power 24 hours after admission to the intensive care unit for mediastinitis risk. This simple tool helps stratify patients according to this risk, thus identifying high-risk patients for preventive measures. In our patient cohort, Med-Score 24 performed better than other scores used for this purpose., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: This systematic review and meta-analysis was performed to determine whether timing or type of tracheostomy was associated with superficial or deep sternal wound infections after cardiac surgery., Methods: All studies reporting the incidence of sternal wound infection after tracheostomy in patients undergoing cardiac surgery were collected and analyzed. Subgroup analyses determined a priori included timing of tracheostomy and type of procedure (open vs percutaneous). All analyses used the random effects model. A meta-regression analysis was performed on the proportion of sternal wound infection and number of days between tracheostomy and initial cardiac surgery., Results: A total of 13 studies met inclusion criteria. The incidence of sternal wound infection across all studies reported was 7% (95% confidence interval [CI], 4-10). The percutaneous tracheostomy group had a sternal wound infection proportion of 3% (95% CI, 1-8), and the open tracheostomy group had a sternal wound infection proportion of 9% (95% CI, 5-14). The incidence of sternal wound infection with early (<14 days) (7%; 95% CI, 3-11) versus late (≥14 days) (7%; 95% CI, 4-10) tracheostomy was similar. Meta-regression demonstrated no significant relationship between incidence of sternal wound infection and number of days between tracheostomy and initial cardiac surgery (R 2  = 6.13%, P = .72). Reported secondary outcomes included 30-day and 1-year mortality, which were high at 23% (95% CI, 19-28) and 63% (95% CI, 43-80), respectively., Conclusions: The incidence of sternal wound infection after tracheostomy in patients undergoing cardiac surgery remains high at 7% (95% CI, 4-10). Open or percutaneous tracheostomy after cardiac surgery is a feasible option because the incidence of sternal wound infection and short-term mortality are comparable. Moreover, the timing of tracheostomy (early or late) had comparable rates of sternal wound infection and short-term mortality., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns., Methods: This was a retrospective case review of 9 patients with sternal wound dehiscence over an 18-month period between 2013 and 2015. Seven of the 9 patients received a single IMAP flap to cover full-length sternal wounds, including 4 with a fasciocutaneous flap and 3 with a musculocutaneous flap., Results: All of the patients were male, with a mean age of 68 years. The mean number of perforators was 1.3, with a mean perforator diameter of 1.5 mm. In all cases, the torsion angle was 80 degrees, with a translational pedicle movement of 1 to 2 cm. There were no instances of total flap failure and only 2 cases of partial flap necrosis, which were managed conservatively. One flap, performed when both internal mammary arteries had been harvested previously, showed complete survival., Conclusions: The IMAP flap has an advantage in its the ability to reconstruct the entire length of a sternotomy wound from the suprasternal notch to the xiphisternum with relatively minimal dissection and morbidity compared with more conventional flaps such as pectoralis major, rectus, and omental flaps. Nevertheless, caveats for its use remain, such as in patients with vasopressor therapy and the resulting subclavicular scar, which is unaesthetic in women. Overall, the IMAP flap is an attractive reconstructive tool specifically in stable male patients with noninfected sternotomy wound dehiscence with a defect width of up to 7 cm. In this patient subset, it is the ideal first-line reconstructive tool., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Mitral valve surgery is increasingly performed through minimally invasive approaches. There are limited data regarding the cost of minimally invasive mitral valve surgery. Moreover, there are no data on the specific costs associated with mitral valve surgery. We undertook this study to compare the costs (total and subcomponent) of minimally invasive mitral valve surgery relative to traditional sternotomy., Methods: All isolated mitral valve repairs performed in our health system from March 2012 through September 2013 were analyzed. To ensure like sets of patients, only those patients who underwent isolated mitral valve repairs with preoperative Society of Thoracic Surgeons scores of less than 4 were included in this study. A total of 159 patients were identified (sternotomy, 68; mini, 91). Total incurred direct cost was obtained from hospital financial records., Results: Analysis demonstrated no difference in total cost (operative and postoperative) of mitral valve repair between mini and sternotomy ($25,515 ± $7598 vs $26,049 ± $11,737; P = .74). Operative costs were higher for the mini cohort, whereas postoperative costs were significantly lower. Postoperative intensive care unit and total hospital stays were both significantly shorter for the mini cohort. There were no differences in postoperative complications or survival between groups., Conclusions: Minimally invasive mitral valve surgery can be performed with overall equivalent cost and shorter hospital stay relative to traditional sternotomy. There is greater operative cost associated with minimally invasive mitral valve surgery that is offset by shorter intensive care unit and hospital stays., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Sternal wound infections are serious postoperative complications that increase the length of hospital stay and healthcare costs. The benefit of implantable gentamicin-collagen sponges in reducing sternal wound infections has been questioned in a recent multicenter trial. We aimed to perform a comprehensive meta-analysis of studies assessing the efficacy of implantable gentamicin-collagen sponges in sternal wound infection prevention., Methods: Multiple databases were screened for studies assessing the efficacy of implantable gentamicin-collagen sponges after heart surgery. The primary end point was sternal wound infection, and secondary end points were the occurrence of deep sternal wound infection, superficial sternal wound infection, mediastinitis, and mortality. Randomized controlled trials and observational studies were analyzed separately. By means of meta-regression, we examined the correlation between sternal wound infection and extent to which the bilateral internal thoracic artery was harvested., Results: A total of 14 studies (N = 22,135, among them 4 randomized controlled trials [N = 4672]) were included in the analysis. Implantable gentamicin-collagen sponges significantly reduced the risk of sternal wound infection by approximately 40% when compared with control (risk ratio [RR], 0.61; 95% confidence interval [CI], 0.39-0.98; P = .04 for randomized controlled trials and RR, 0.61; 95% CI, 0.42-0.89; P = .01 for observational studies). A similar, significant benefit was demonstrated for deep sternal wound infection (RR, 0.60; 95% CI, 0.42-0.88; P = .008) and superficial sternal wound infection (RR, 0.60; 95% CI, 0.43-0.83; P = .002). The overall analysis revealed a reduced risk of mediastinitis (RR, 0.64; 95% CI, 0.45-0.91; P = .01). The risk of death was unchanged. A significant positive linear correlation (P = .05) was found between the log RR of sternal wound infection and the percentage of patients receiving bilateral internal thoracic artery grafts., Conclusions: Implantable gentamicin-collagen sponges significantly reduce the risk of sternal wound infection after cardiac surgery, with evidence consistent in randomized and observational-level data. However, the extent of this benefit might be attenuated in patients receiving bilateral internal thoracic artery grafts., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost., Methods: Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed., Results: A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02)., Conclusions: Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: For transcatheter aortic valve replacement (TAVR), transaortic (TAo) and transapical (TA) approaches are major alternatives in cases unsuitable for the transfemoral approach. Partial J-sternotomy is a widely used access for TAo. However, redo sternotomy or right-sided aorta may preclude this access, and right anterior thoracotomy is potentially beneficial in these cases. This study sought to evaluate the TAo approach using thoracotomy (T-TAo) and compare it to the TAo approach using a sternotomy (S-TAo) and a TA approach., Methods: In a large single-center series, consecutive TAVR patients were studied. Procedural/clinical outcomes of the T-TAo, S-TAo, and TA groups were compared up to a 30 days follow-up period., Results: Of 872 TAVR patients, 22 (2.5%) were T-TAo, 29 (3.3%) were S-TAo, and 86 (9.9%) were TA approaches. The TA group showed the shortest intensive care unit stay, with a median 2.0 (interquartile range 1.0-3.0) days: for T-TAo it was 3.0 (2.0-5.3) and for S-TAo, 3.0 (3.5-5.0) (P < .001). Although it was not statistically significant, the T-TAo group showed numerically less mortality (1 [4.5%], 5 [17.9%], and 8 [9.4%] in the T-TAo, S-TAo, and TA groups, respectively; P = .30), with no difference in other endpoints, including stroke/transient ischemic attack, rehospitalization, and paravalvular leak. Additionally, computed tomographic assessment revealed that T-TAo facilitated a more coaxial approach than S-TAo: 20.4° ± 8.2° versus 30.6° ± 8.2° (P < .001)., Conclusions: T-TAo is a feasible approach that can provide greater coaxiality. This option allows tailored and optimal access to the individual patient and facilitates a treatment strategy in nontransfemoral TAVR patients., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of our study was to evaluate the early outcomes and 1-year survival of patients undergoing minimally invasive aortic valve replacement with the Perceval S sutureless valve for severe aortic stenosis., Methods: From March 2010 to March 2013, 281 high-risk patients underwent minimally invasive aortic valve replacement with the Perceval S sutureless valve through either right anterior minithoracotomy (n = 164) or upper ministernotomy (n = 117) at 2 cardiac centers., Results: The overall in-hospital mortality was 0.7% (2 patients). The overall median cardiopulmonary bypass and crossclamp time was 81 minutes (interquartile range, 68-98) and 48 minutes (interquartile range, 37-60), respectively. Postoperative stroke occurred in 5 patients (1.8%). The incidence of paravalvular leak greater than 1 of 4 and atrioventricular block requiring pacemaker implantation was 1.8% (5 patients) and 4.2% (12 patients), respectively. No migration occurred, and the mean postoperative gradient was 13 ± 4 mm Hg. At a median follow-up of 8 months (interquartile range, 4-14), the overall survival was 90%., Conclusions: Minimally invasive aortic valve replacement with the Perceval S sutureless valve in high-risk patients is a safe and reproducible procedure associated with excellent hemodynamic results, postoperative outcomes, and 1-year survival., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Small series of thoracotomy for mitral valve repair have demonstrated clinical benefit. This multi-institutional administrative database analysis compares outcomes of thoracotomy and sternotomy approaches for mitral repair., Methods: The Premier database was queried from 2007 to 2011 for mitral repair hospitalizations. Premier contains billing, cost, and coding data from more than 600 US hospitals, totaling 25 million discharges. Thoracotomy and sternotomy approaches were identified through expert rules; robotics were excluded. Propensity matching on baseline characteristics was performed. Regression analysis of surgical approach on outcomes and costs was modeled., Results: Expert rule analysis positively identified thoracotomy in 847 and sternotomy in 566. Propensity matching created 2 groups of 367. Mortalities were similar (thoracotomy 1.1% vs sternotomy 1.9%). Sepsis and other infections were significantly lower with thoracotomy (1.1% vs 4.4%). After adjustment for hospital differences, thoracotomy carried a 17.2% lower hospitalization cost (-$8289) with a 2-day stay reduction. Readmission rates were significantly lower with thoracotomy (26.2% vs 35.7% at 30 days and 31.6% vs 44.1% at 90 days). Thoracotomy was more common in southern and northeastern hospitals (63% vs 37% and 64% vs 36%, respectively), teaching hospitals (64% vs 36%) and larger hospitals (>600 beds, 78% vs 22%)., Conclusions: Relative to sternotomy, thoracotomy for mitral repairs provides similar mortality, less morbidity, fewer infections, shorter stay, and significant cost savings during primary admission. The markedly lower readmission rates for thoracotomy will translate into additional institutional cost savings when a penalty on hospitals begins under the Affordable Care Act's Hospital Readmissions Reduction Program., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study presents a review of our experience with minimally invasive mitral valve surgery (MIMVS) in patients with a previous cardiac procedure performed through a sternotomy over a 10-year period., Methods: From November 2003 to August 2013, 173 patients (age 61.3 ± 12.4 years) underwent reoperative MIMVS through a right minithoracotomy. Previous operations were coronary artery bypass grafting (n = 49; 28.6%), a mitral valve procedure (n = 120; 70.1%), an aortic valve procedure (n = 32; 18.7%), and other operations (n = 14; 8.1%). The mean euroSCORE was 11.2 ± 3.8. The time to redo surgery was 6.9 ± 4.2 years., Results: Procedures were performed with central aortic cannulation in 55 patients (31.7%) and peripheral cannulation in 118 (68.3%). A transthoracic clamp was used in 58 patients (33.5%), an endoaortic balloon in 72 (41.6%), hypothermic ventricular fibrillation in 23 (13.2%), and beating heart in 20 (11.5%). Mean cardiopulmonary bypass and crossclamp times were 160 ± 58 minutes and 82 ± 49 minutes, respectively. Mitral repair was performed in 53 patients (30.6%). Forty-three patients (24.7%) had an additional cardiac procedure. Conversion to sternotomy was necessary in 2 patients (1.1%) and reoperation for bleeding in 11 patients (6.3%). Thirty-day mortality was 4.1% (n = 7). Major morbidities included stroke (n = 11; 6%) and new-onset dialysis requirement (n = 4; 2.3%). The mean blood transfusion requirement was 1.4 ± 1.1 units. Mean follow-up was 3.3 ± 2.6 years. Survival at 1, 5, and 10 years was 93.1% ± 1.9%, 87.5% ± 2.7%, and 79.7% ± 3.8%, respectively., Conclusions: Reoperative mitral valve surgery can be safely performed through a right minithoracotomy with good early and late outcomes. The avoidance of extensive surgical dissection, optimal valve exposure, and low blood transfusion are the main advantages of this technique., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To update the current evidence on mitral valve surgery through a lateral minithoracotomy versus median sternotomy., Methods: A comprehensive literature research was performed for studies comparing mitral valve surgery through a right lateral minithoracotomy (MIVS) and median sternotomy in MEDLINE, EMBASE, Cochrane Central, CTSnet, and Google Scholar for the most recent literature up to April 2013. A systematic review and meta-analysis was performed on the studies found in the literature., Results: More than 20,000 patients from 45 studies were included in this study. Stroke rate and all-cause mortality up to 30 days was similar in both groups. The length of stay in the intensive care unit, respirator dependence, and hospital stay were significantly shorter in the MIVS group. Furthermore, blood drainage volume and blood transfusions were decreased in the MIVS group. In contrast, cardiopulmonary bypass time, crossclamp time, and procedure time were longer in the MIVS group. Postoperative new atrial fibrillation was less in the MIVS group. More aortic dissections occurred in the MIVS group. The rates of reexploration and postoperative renal failure were similar in both groups., Conclusions: MIVS and conventional mitral valve surgery have a similar perioperative outcome. Mitral valve surgery via a right lateral minithoracotomy seems to be favorable with regard to resource-related outcome., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical site infection (SSI), particularly deep sternal wound infection (DSWI), is a serious complication after cardiovascular surgery because of its high mortality rate. We evaluated the effectiveness of an SSI bundle to reduce DSWI and identify the risk factors for DSWI., Methods: During the period January 2004 to February 2012, 1374 consecutive patients undergoing cardiovascular surgery via sternotomy were included. The cohort was separated into periods from January 2004 through February 2007 (period I, 682 patients) and March 2007 through February 2012 (period II, 692 patients). During period II, all preventive measures for DSWI were completed as an SSI bundle. We compared the DSWI rate between the 2 periods. Univariate and multivariate analyses were performed for the entire period to identify the risk factors for DSWI., Results: DSWI occurred in 13 patients (1.9%) during period I and in 1 patient (0.14%) during period II. The DSWI rate during period II was significantly decreased by 93%, compared with period I (P=.001). Independent risk factors for DSWI included obesity (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.00-11.75; P=.049), the use of 4 sternal wires (OR, 8.2; 95% CI, 1.39-48.14; P=.020), long operative time (OR, 4.4; 95% CI, 1.20-16.23; P=.026), and postoperative renal failure (OR, 9.0; 95% CI, 2.44-33.30; P=.001)., Conclusions: Complete implementation of simple multidisciplinary prevention measures as a bundle can greatly decrease the incidence of DSWI., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Optimal management of poststernotomy mediastinitis is controversial. Negative pressure wound treatment improves wound environment and sternal stability with low surgical invasiveness. Our protocol was based on negative pressure followed by delayed surgical closure. The aim of this study was to provide the results at early follow-up and to identify the risk factors for adverse outcome., Methods: In 5400 cardiac procedures, 44 consecutive patients with mediastinitis were enrolled in the study. Mediastinitis treatment was based on urgent debridement and negative pressure as the first-line approach. After wound sterilization, chest closure was achieved by elective pectoralis muscle advancement flap. Each patient's hospital data were collected prospectively. Variables included patient demographics and clinical and biological data. Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated at the time of diagnosis and 48 hours after debridement. Focus outcome measures were mediastinitis-related death and need for reintervention after pectoralis muscle closure., Results: El Oakley type I and type IIIA mediastinitis were the most frequent types (63.6%). Methicillin-resistant Staphylococcus aureus was present in 25 patients (56.8%). Mean APACHE II score was 19.4±4 at the time of diagnosis, and 30 patients (68.2%) required intensive care unit transfer before surgical debridement. APACHE II score improved 48 hours after wound debridement and negative pressure application (mean value, 19.4±4 vs 7.2±2; P=.005) independently of any other variables included in the study. One patient in septic shock at the time of diagnosis died (2.2%)., Conclusions: Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The effectiveness of the routine retrosternal placement of a gentamicin-impregnated collagen sponge (GICS) implant before sternotomy closure is currently a matter of some controversy. We aimed to develop a scoring system to guide decision making for the use of GICS to prevent deep sternal wound infection., Methods: Fast backward elimination on predictors, including GICS, was performed using the Lawless and Singhal method. The scoring system was reported as a partial nomogram that can be used to manually obtain predicted individual risk of deep sternal wound infection from the regression model. Bootstrapping validation of the regression models was performed., Results: The final populations consisted of 8750 adult patients undergoing cardiac surgery through full sternotomy during the study period. A total of 329 patients (3.8%) received GICS implant. The overall incidence of deep sternal wound infection was lower among patients who received GICS implant (0.6%) than patients who did not (2.01%) (P=.02). A nomogram to predict the individual risk for deep sternal wound infection was developed that included the use of GICS. Bootstrapping validation confirmed a good discriminative power of the models., Conclusions: The scoring system provides an impartial assessment of the decision-making process for clinicians to establish if GICS implant is effective in reducing the risk for deep sternal wound infection in individual patients undergoing cardiac surgery through full sternotomy., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: There are limited data defining the risk of repeat sternotomy for surgical aortic valve replacement in octogenarian patients with aortic valve stenosis and previous coronary artery bypass graft operation. Our study assesses the risk of operation., Methods: We conducted a retrospective review of 629 octogenarian patients with aortic stenosis who received isolated surgical aortic valve replacement between January 1993 and December 2011. Patient characteristics included age 83.7±3.2 years, male sex in 322 patients (51.2%), and Society of Thoracic Surgeons predicted risk of mortality of 6.2%±4.4%. Operations included a primary sternotomy in 518 patients (82.4%) and a repeat sternotomy in 111 patients (17.6%) who had previous coronary artery bypass graft operation. Patients with other cardiac operations were excluded from the study., Results: Cardiopulmonary bypass time was longer with repeat sternotomy (88.0±45.7 minutes) in comparison to primary sternotomy (66.5±25.1; P<.001); but there was no difference in the aortic crossclamp time (51.1±19.7 minutes vs 49.2±17.7 minutes; P=.282). Stroke occurred in 3 patients (2.7%) following repeat sternotomy and in 10 (1.9%) after primary sternotomy (P=.710). Rates of myocardial infarction, renal failure, and reoperation for bleeding were similar between the 2 groups. Operative mortality occurred in 7 patients (6.4%) after repeat sternotomy and in 19 patients (3.7%) following primary sternotomy (P=.196). Repeat sternotomy was not predictive of operative mortality., Conclusions: Repeat sternotomy and surgical aortic valve replacement can be done with low risk in octogenarian patients with previous coronary artery bypass graft operation., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The Cox maze IV procedure has the best results for the surgical treatment of atrial fibrillation. It has been traditionally performed through sternotomy with excellent outcomes, but this has been considered to be too invasive. An alternative approach is to perform a less invasive right anterolateral minithoracotomy. This series compared these approaches at a single center in consecutive patients., Methods: Patients undergoing a Cox maze IV procedure (n = 356) were retrospectively reviewed from January 2002 to February 2014. Patients were stratified into 2 groups: right minithoracotomy (RMT; n = 104) and sternotomy (ST; n = 252). Preoperative and perioperative variables were compared as well as long-term outcomes. Patients were followed up for 2 years and rhythm was confirmed with an electrocardiogram or prolonged monitoring., Results: Freedom from atrial tachyarrhythmias off antiarrhythmic drugs was 81% and 74% at 1 and 2 years, respectively, using an RMT approach and was not significantly different from the ST group at these same time points. The overall complication rate was lower in the RMT group (6% vs 13%, P = .044) as was 30-day morality (0% vs 4%, P = .039). Median length of stay in the intensive care unit was lower in the RMT group than in the ST group (2 days [range, 0-21 days] vs 3 days [range, 1-61 days]; P = .004) as was median hospital length of stay (7 days [range, 4-35 days] vs 9 days [range, 1-111 days]; P < .001)., Conclusions: The Cox maze IV procedure performed through a right minithoracotomy is as effective as sternotomy in the treatment of atrial fibrillation. This approach was associated with fewer complications, decreased mortality and decreased length of stay in the intensive care unit and hospital length of stay., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: One of the challenges that exists when discussing the Cox maze procedure for atrial fibrillation (AF) with patients is predicting the success for a given patient. The purpose of the present study was to develop a scoring system using well-established clinical factors to predict the probability of sinus rhythm (SR) after surgery., Methods: The data from patients 1 and 2 years postoperatively were analyzed using logistic regression to predict SR, including the most accepted variables associated with failure (age, left atrium size, AF duration, AF type). Regression models were applied using hypothetical patients to examine the predicted probability of SR., Results: The predictors of 1-year SR were a shorter AF duration and greater surgeon experience performing surgical ablation. The predictors at 2 years were a shorter AF duration and smaller left atrium. The 1-year prediction model applied to hypothetical data found a 1-cm increase in left atrial size associated with a 0.4% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of surgeon experience associated with a 1.0% reduction. The 2-year model found a 1-cm increase in left atrial size associated with a 1.0% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of experience associated with a 0.2% reduction., Conclusions: Our findings are the first step in establishing a risk scoring system to better predict the outcomes after surgical ablation for AF and improve the ability to discuss the risk and benefits with patients., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study was undertaken to determine whether topical vancomycin would further reduce the incidence of sternal infections in the presence of perioperative antibiotics and tight glycemic control., Methods: A total of 1075 consecutive patients undergoing cardiac surgery from December 2007 to August 2013 receiving topical vancomycin (2.5 g in 2 mL of normal saline) applied as a slurry to the cut edges of the sternum were compared with 2190 patients from December 2003 to November 2007 who did not receive topical vancomycin. All patients received perioperative antibiotics (cefazolin 2 g intravenously every 8 hours and vancomycin 1 g intravenously every 12 hours) on induction of anesthetic and continuing for 48 hours; and intravenous insulin infusions to maintain serum blood glucose level between 120 and 180 mg/dL., Results: Patients receiving topical vancomycin had less superficial sternal infections (0% vs 1.6%; P < .0001), deep sternal infections (0% vs 0.7%; P = .005), any type of sternal infection (0% vs 2.2%; P < .0001) and significantly less sternal infections of any type in patients with diabetes mellitus (0% vs 3.3%; P = .0004)., Conclusions: Topical vancomycin applied to the sternal edges, in conjunction with perioperative antibiotics and tight glycemic control, helps to eliminate wound infections in cardiac surgical patients., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To compare the outcomes of right minithoracotomy (RT) versus ministernotomy (MS) in patients undergoing minimally invasive aortic valve replacement (AVR)., Methods: From January 2005 to December 2011, 406 patients underwent minimally invasive AVR, of whom 251 patients were in the RT group and 155 were in the MS group., Results: The overall in-hospital mortality was 1.2% with no difference between the 2 groups (1.2% in RT vs 1.3% in MS). Patients undergoing minimally invasive AVR using RT had a lower incidence of postoperative atrial fibrillation (19.5% vs 34.2%, P = .01), shorter ventilation time (median, 7 vs 8 hours; interquartile range, 5-9 vs 6-12 hours, P = .003), intensive care unit stay (median 1 vs 1 day; interquartile range, 1-1 vs 1-2 days; P = .001), and hospital stay (median, 5 vs 6 days; interquartile range, 5-6 vs 5-8 days; P = .0001). No difference was found in terms of cardiopulmonary time, crossclamping time, postoperative stroke, re-exploration for bleeding, or blood transfusion., Conclusions: Minimally invasive AVR using RT was associated with lower postoperative morbidities and a shorter hospital stay than MS., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Minimally invasive cardiac surgery is becoming a safe and cosmetic alternative to standard median sternotomy (SMS). In the present retrospective study, we reviewed our results and experience with the totally thoracoscopic (TTS) and right vertical infra-axillary thoracotomy (RVIAT) techniques for atrial septal defect closure compared with SMS., Methods: From December 2010 to February 2012, 198 patients underwent repair of atrial septal defect using the TTS technique (n = 66), RVIAT (n = 59), or SMS (n = 73). Cardiopulmonary bypass was achieved peripherally in the TTS group and directly in the RVIAT and SMS groups., Results: The procedures were performed successfully in all 3 groups, and no in-hospital mortality occurred. No patient required conversion to SMS in the TTS group, although 2 patients did so in the RVIAT group. The cardiopulmonary bypass time was 87.26 ± 21 minutes in the TTS group, 41.81 ± 13.97 minutes in the RVIAT group, and 36.99 ± 10.84 minutes in the SMS group (P < .01). The crossclamp time was 32.86 ± 13.36, 22.54 ± 9.08, and 19.23 ± 6.92 minutes in the TTS, RVIAT, and SMS groups, respectively (P < .01). The total incision length in the SMS group (7.45 ± 1.54 cm) was longer than that in the other groups (TTS group, 5.21 ± 0.63 cm; RVIAT group, 6.48 ± 1.37 cm); the difference was statistically significant (P < .01)., Conclusions: The TTS technique and RVIAT can both be performed with favorable cosmetic and acceptable clinical results for closing atrial septal defects. They are promising alternatives to SMS and merit additional study., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: We sought to describe the prevalence of restrictive lung function in structural congenital heart disease and to determine the effect of cardiothoracic surgical intervention., Methods: The data from a retrospective review of the spirometry findings from pediatric patients with structural congenital heart disease were compared with the data from 220 matched controls. Restrictive lung function was defined as a forced vital capacity of <80%, with a preserved ratio of the forced expiratory volume in the first second to forced vital capacity of >80%., Results: Of the children with congenital heart disease, 20% met the criteria for restrictive lung function compared with 13.2% of the controls (P = .03). The prevalence in those with congenital heart disease without a surgical history was similar to that of the controls (odds ratio, 0.62; 95% confidence interval, 0.34-1.13). Restrictive lung function was more likely if surgical intervention had occurred within the first year of life (odds ratio, 1.96; 95% confidence interval, 1.08-3.55; P < .0001). Those who had undergone both sternotomy and thoracotomy had a greater prevalence of restrictive lung function than those who had undergone sternotomy or thoracotomy alone (54.2% vs 25.6% and 23.5%, respectively; P < .0001). The prevalence of restrictive lung function increased significantly with each additional surgical intervention (odds ratio, 1.61; 95% confidence interval, 1.29-2.01; P < .0001)., Conclusions: Restrictive lung function was more prevalent in those with congenital heart disease after cardiothoracic surgical intervention than in the controls or patients without surgical intervention. The prevalence was also greater with surgical intervention at an earlier age. The risk was equivalent when sternotomy alone was compared with thoracotomy alone but was significantly greater when both sternotomy and thoracotomy were performed. The risk increased with each additional surgery performed., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Patients with severe heart failure might benefit from reduced operative trauma, but rarely undergo less-invasive valve surgery. The present study compared the outcomes of less-invasive heart valve surgery with those of complete sternotomy in such patients., Methods: From January 1995 to July 2010, 871 patients in New York Heart Association class III or IV underwent valve surgery (aortic or mitral, or both). A less-invasive approach was used in 205. Propensity score matching yielded 185 matched pairs for outcomes comparison adjusted for patient characteristics and 139 pairs adjusted further for individual surgeon., Results: Without considering surgeons, myocardial ischemic times (59 ± 27 vs 64 ± 26 minutes, P = .04), cardiopulmonary bypass times (75 ± 35 vs 86 ± 34 minutes, P < .0001), and intensive care unit stays (median, 24 vs 43 hours; P = .007) were shorter for less-invasive surgery. Hospital morbidity, mortality (1.6% [3 of 185] vs 2.7% [5 of 185]; P = .5), and long-term survival (53% and 48% at 12 years; P = .3) were similar. After considering the surgeon, these benefits were not apparent; rather, efficiency, safety, and effectiveness were equivalent to those of complete sternotomy. Thus, myocardial ischemic (63 ± 30 vs 62 ± 25 minutes, P = .8) and cardiopulmonary bypass (80 ± 40 vs 81 ± 31 minutes, P = .5) times were similar, as were intensive care unit stay (median, 28 vs 30 hours; P = .09), postoperative complications, in-hospital mortality (2.2% [3 of 139] vs 3.6% [5 of 139]; P = .5), and long-term survival (57% and 53% at 12 years; P = .5)., Conclusions: In selected patients with severe heart failure, less-invasive valve surgery is a viable option, yielding at least equivalent efficiency, safety, and effectiveness to complete sternotomy. However, achieving these outcomes requires surgeons experienced in less-invasive surgery., (Copyright © 2014. Published by Mosby, Inc.)

Objective: Patients with congenital heart disease frequently survive into adulthood, and many of them will require repeat surgery. Often, the unique anatomy can make reoperative sternotomy and the conduct of cardiopulmonary bypass challenging. We evaluated the utility of preoperative 3-dimensional imaging and presternotomy femoral cutdown in reoperative adult congenital heart disease surgery., Methods: We retrospectively studied 205 adult patients, who had undergone reoperative cardiac surgery for congenital heart disease from 2006 to 2011. Using the operative history and 3-dimensional preoperative imaging findings, an algorithm was created to determine whether femoral cutdown or cannulation should be performed before sternal reentry. Analyses were performed to determine the benefits of this strategy. In addition, analyses were performed to identify adverse outcomes related to this strategy., Results: Presternotomy femoral intervention was performed in 112 of 205 patients (55%)-femoral cutdown alone in 69 (34%) and femoral cutdown, cannulation, and institution of cardiopulmonary bypass in 43 (21%). Of the 19 patients (9%) with a cardiac injury, femoral cutdown had already been performed in 17, of whom 10 had also undergone cannulation. Only 2 patients required urgent femoral cutdown or cannulation. A strong correlation was found between the site of injury predicted by the preoperative algorithm and the actual site of cardiac injury (88%). In both univariate and multivariate models, the risk factors for cardiac injury included a history of cardiac injury during sternal reentry (18% vs 1%, P = .0001), proximity of the right ventricular outflow tract to the posterior chest wall (35% vs 14%, P = .04), and increased reoperative sternotomy incidence (P = .01). In 31 patients, despite safe reentry, the femoral vessels were used as a preferential site of venous (n = 6), arterial (n = 9), or venous and arterial cannulation (n = 16) because of anatomic constraints within the chest cavity. Three patients experienced groin complications (pseudoaneurysm, abscess, ischemia) requiring surgery., Conclusions: Cardiac injury during reoperative surgery in adults with congenital heart disease is not uncommon. The preoperative history and imaging findings could be predictive of certain cardiac injury patterns. Using the preoperative history and 3-dimensional imaging findings, a more selective algorithm for presternotomy femoral intervention might be warranted., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)