Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials.

Background Mini-sternotomy for isolated aortic valve replacement aims to reduce operative trauma hastening recovery and improving the cosmetic outcome of cardiac surgery. The short-term clinical benefits from the mini-sternotomy are presumed to arise because the incision is less extensive and the lower half of the chest cage remains intact. The basic conduct of virtually all other aspects of the aortic valve replacement procedure remains the same. Therefore, similar long-term outcomes are to be expected. Objectives To conduct a meta-analysis of the only available randomised controlled trials (RCT) in the published English literature. Data sources Electronic search for relevant publications in MEDLINE, EMBASE and CENTRAL databases were performed. Four studies met the criteria. Study eligibility criteria RCT comparing minimally invasive (inverted C or L (J)-shaped) hemi-sternotomy versus conventional sternotomy for adults undergoing isolated aortic valve replacement using standard cardiopulmonary bypass technique. Methods Outcome measures were the length of positive pressure ventilation, blood loss, intensive care unit (ICU) and hospital stay. Results The length of ICU stay was significantly shorter by 0.57 days in favour of the mini-sternotomy group (CI -0.95 to -0.2; p=0.003). There was no advantage in terms of duration of ventilation (CI -3.48 to 0.36; p=0.11). However, there was some evidence to suggest a reduction in blood loss and the length of stay in hospital in the mini-sternotomy group. This did not prove to be statistically significant (154.17 ml reduction (CI -324.51 to 16.17; p=0.08) and 2.03 days less (CI -4.12 to 0.05; p=0.06), respectively). Limitations This study includes a relatively small number of subjects (n=220) and outcome variables. The risk of bias was not assessed during this meta-analysis. Conclusion Mini-sternotomy for isolated aortic valve replacement significantly reduces the length of stay in the cardiac ICU. Other short-term benefits may include a reduction in blood loss or the length of hospital stay.

Functional small-diameter neovessels created using endothelial progenitor cells expanded ex vivo.

Arterial conduits are increasingly preferred for surgical bypass because of inherent functional properties conferred by arterial endothelial cells, especially nitric oxide production in response to physiologic stimuli. Here we tested whether endothelial progenitor cells (EPCs) can replace arterial endothelial cells and promote patency in tissue-engineered small-diameter blood vessels (4 mm). We isolated EPCs from peripheral blood of sheep, expanded them ex vivo and then seeded them on decellularized porcine iliac vessels. EPC-seeded grafts remained patent for 130 days as a carotid interposition graft in sheep, whereas non-seeded grafts occluded within 15 days. The EPC-explanted grafts exhibited contractile activity and nitric-oxide-mediated vascular relaxation that were similar to native carotid arteries. These results indicate that EPCs can function similarly to arterial endothelial cells and thereby confer longer vascular-graft survival. Due to their unique properties, EPCs might have other general applications for tissue-engineered structures and in treating vascular diseases.

Incidence and size of lateral costal artery in 103 patients.

BACKGROUND: The internal mammary artery is used widely as a conduit for coronary artery bypass grafting. Most practicing cardiac surgeons are unaware of an aberrant side branch, the lateral costal artery (LCA), that arises proximally. Unligated, this side branch has been held responsible for early recurrence of angina in a small number of patients in the literature. In this study we identified the incidence and length of the LCA. METHODS: We studied 103 patients who had coronary artery bypass grafting with bilateral internal mammary arteries. The presence or absence of an LCA was noted, and a record was made of the number of intercostal spaces traversed. RESULTS: Thirty-one of 103 patients had an LCA on one or the other side. Twenty-five patients had bilateral LCAs in which length was equal on both sides in 18. Median length was two intercostal spaces (range, one to six). The LCA extended to the fifth space or beyond in 5 patients. CONCLUSIONS: The LCA was present in one third of patients who had coronary artery bypass grafting. A few patients had vessels sizable enough to raise concerns about recurrence of angina. It is prudent to exclude the presence of an LCA in all patients who have cardiac operations.

Breaking the rules! Cardiac injury from remote entry sites.

An unusual case of penetrating injury to the heart is reported. This presented late, after an initial silent period. A high index of suspicion must be maintained when chest injuries are managed conservatively. If there is doubt, a subxiphoid pericardial window may allow cardiac injury to be excluded.

Acute adrenal insufficiency after coronary artery bypass grafting.

We report a case of acute adrenal insufficiency after elective coronary artery bypass grafting. This potentially fatal complication has been reported only once before in the cardiac surgical literature, more than 15 years ago. Unfortunately, adrenal insufficiency in this setting is easily confused with the clinical picture of septic shock or an acute abdominal pathology, and it is our belief that this condition could easily escape recognition and thus contribute to needless mortality.

Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment.

Ventricular free wall rupture is a recognized complication of myocardial infarction. In recent years, the widespread availability of echocardiography has enabled prompt antemortem diagnosis. Consequently, an avenue for lifesaving surgical intervention has emerged for this hitherto fatal condition. We review the pathology and discuss strategies for diagnosis, resuscitation, and definitive surgical intervention. We illustrate this review using our experience with a patient whose condition was diagnosed by transthoracic echocardiography and who successfully underwent emergency operation.