Does the atrial incision affect rates of early postoperative atrial arrhythmias in mitral valve surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients undergoing mitral valve surgery, does atrial incision affect early postoperative rates of atrial arrhythmia'. Two hundred and four papers were found. Nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Data suggest that a transeptal incision is associated with increased rates of postoperative atrial arrhythmia compared with direct left atriotomy.

Thoracoabdominal Aortic Aneurysm - The Branch First Technique.

Surgical management of thoracoabdominal aortic aneurysms is complex. In particular, maintaining adequate spinal cord and reno-visceral protection during the operation can be challenging. We describe here a branch-first technique developed at our institution, endeavoring to minimized renal and visceral organ ischemic time, decrease risk of spinal cord injury, and provide a controlled and uncluttered field in which the surgeon can operate.

Prospective, randomized, controlled trial of polymer cable ties versus standard wire closure of midline sternotomy.

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.

Minimally Invasive Tracheal Resection: Cervical Approach Plus Video-Assisted Thoracoscopic Surgery.

Tracheal resection for adenoid cystic carcinoma (ACC) is a well-documented procedure. Surgical resection of these lesions offers patients the greatest potential chance of survival. Midtracheal tumors are usually resected through a maximally invasive sternotomy or thoracotomy. We report a midtracheal resection of a symptomatic ACC in a 25-year-old man by video-assisted thoracoscopic hilar release and suprasternal anastomotic approaches. The patient's recovery was complicated by chylothorax and pneumonia.

Procedure-specific Cardiac Surgeon Volume associated with Patient outcome following Valve Surgery, but not Isolated CABG Surgery.

PURPOSE: Trends towards surgical sub-specialisation to improve patient-outcomes are well-documented and largely supported by evidence. However few studies have examined whether this benefit exists within adult-cardiac surgery. To answer whether sub-specialisation within adult-cardiac surgery improves patient-outcomes, this study assessed the relationship between procedure-specific and total-cardiac surgeon-volume and mortality and morbidity in cardiac-valve and coronary artery bypass grafting (CABG) surgery. METHODS: Data came from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registry from 2001 to 2010 and included 23 hospitals, 109 surgeons, 20,619 patients with isolated-CABG-surgery and 11,536 patients with a valve-procedure. Hierarchical logistic regression using generalised estimating equations was used to analyse outcomes. Measures included operative-mortality and occurrence of a complication (deep sternal wound infection, new stroke, acute kidney injury). RESULTS: Crude operative mortality (and complication rates) were 1.7% (4.9%) and 4% (11%) in the isolated-CABG and valve-surgical populations respectively. A greater procedure-specific surgeon volume was associated with reduced mortality and complication rates in valve-surgery but not isolated-CABG. There was a 33% decrease in odds of dying for every additional 50 valve procedures performed [OR 0.67, p=0.003]. Conversely, greater total-cardiac surgical volume for individual surgeons did not result in improved outcomes, for both isolated-CABG and valve populations. CONCLUSIONS: Our finding of an association between increased valve-specific surgeon volumes with improved valve-surgery outcomes, and absence of an association between these outcomes and annual total-cardiac surgical experience supports the case for sub-specialisation specifically within the field of valve surgery.

Stanford type a aortic dissection in pregnancy: a diagnostic and management challenge.

BACKGROUND: In women under the age of 40, over 50% of type A aortic dissections occur in the obstetric population. This is a complex situation, with potential catastrophic outcomes for mother and child. Time to diagnosis is often delayed by a low degree of suspicion, atypical presentation and difficulties investigating pregnant women. Management requires early involvement of multiple teams and appreciation of potential complications. We report our experience (the largest series described) and describe our surgical strategy. METHODS: A retrospective search of the cardiothoracic surgical database at our centre from 2002 to 2010 identified five pregnant women with type A dissections. RESULTS: Median time to diagnosis was 18.5 h (range 5.5-150 h) and median time from diagnosis to arrival in the operating theatre was 1.5 h (range 0.5-54 h). Four patients underwent concomitant Caesarean section and dissection repair. There was one maternal death and one unrelated foetal death. CONCLUSION: Occurrence of type A aortic dissection in pregnant women is uncommon but potentially catastrophic. A high index of suspicion and timely investigations are necessary to expedite definitive management. Sound surgical strategies and collaboration with appropriate teams are necessary to optimise outcome.

Blunt cardiac rupture in the setting of previous sternotomy.

Most cases of blunt cardiac rupture (BCR) are associated with mortality at the scene of the injury. For the fortunate 13% to 17% of patients who survive the journey to the hospital, the treatment is definitive surgical repair. In the setting of previous sternotomy, the pericardial adhesions may limit the damage and protect against cardiac tamponade. We describe a patient who sustained 2 right ventricular tears from blunt trauma in a motor vehicle accident 18 years after coronary artery bypass graft surgery. He did not demonstrate hemodynamic compromise and was successfully managed conservatively.