[HSF] partial sternotomy

Tea Acuff tacuff at swbell.net
Wed Jan 13 05:24:19 EST 2010 

A "beautiful thing", no?
Tea

Sent from my iPhone

On Jan 12, 2010, at 11:58 PM, Giuseppe Rescigno <grescigno at mac.com> wrote:

We do not perform so man upper hemisternotomy per year (1% of AVR operations). However, I have not seen so many advantages besides a better cosmetic result. Pain is sometimes even worse. I am sorry to stress this point once again, but the real minimally invasive approach is the endovascular one. If we will not catch this message, in the near future we will be completely excluded from aortic stenosis treatment. I am in charge of monitoring  the TAVI program from a surgical standpoint (indications etc) of our center and, believe me, there is no contest: one example: 85 yo frail woman with n2 risk factors, Corevalve implatation with awake patient in less than 1 hour, no residual gradient, no leak! When they will show that follow-up is reasonably good they will enlarge indication to the 75 yo, then 70 etc. We should keep the pace by adopting a hybrid approach; we have the opportunity to use different vascular approaches (subclavian, ascending aorta etc.


Giuseppe


Il giorno 13/gen/10, alle ore 05:52, Dr. Jean Bachet ha scritto:

I agree 300% with Tom and Ani.
Many patients (particularly men, of course) do not care whether they
have a complete or a limited sternotomy and after one year they
generally completely ignore their scar. The less pain, less bleeding,
less hospital stay, better stability of the sternum, etc, argument is in
great part a total myth.  When an unexpected complication occurs with a
minimal approach it might turn to a real catastrophe, whereas it could
have been managed easily with a large approach. The only field in which
I personally see any usefulness of those techniques is video-assisted
mitral surgery. But it has to be done on a regular basis, by very well
trained people and on very well selected patients. Anyway we should not
forget that this kind of procedures (Mitral, Tricuspid, ASD, etc...) can
be perfectly done through a regular right thoracotomy if, for an
understandable esthetic reason (young women) we want to avoid a regular
sternotomy. After a few weeks, only their lover (or husband) will know
that they have been operated on! I have never seen much difference
between an incision of 15 cm and one of 8 or 9. In addition, I have
noticed when observing people doing "minimal invasive" approaches, that
the length of their incision is always largely underestimated. They say
6 cm but if you measure it is often closer to 10 cm.
I am afraid that, unfortunately, a certain number of surgeons promoting
minimal invasive approaches are more keen to demonstrate that they are
very skilled and kind of "supermen" than really interested in the long
term results of the cardiac repair.

Jean BACHET

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
Sent: 12 January 2010 14:17
To: open heart list
Subject: RE: [HSF] partial sternotomy


besides the cosmetic there is absolutely no advantage and in fact
makes the operation harder and higher risk.
Can't wait to hear the responses from that!
Tom



Dr Martin



I dont think you will get much response as anyone true to themselves
will agree what you say is true, for at least the majority of cases.
Indeed even the cosmetic value is questionable - as don said it is
possible to do a sternotomy with a not much larger incision and only few
weeks ago Prasanna presented a hemisternotomy picture from his team
which was anything much minimally invasive and a much larger incision
than many would use for a conventional AVR via sternotomy. Also as has
been stated the (high) position of the scar for an upper hemisternotomy
may make it less cosmetic, even though a smaller incision, compared to a
low skin incision for conventional sternotomy.



As stated too most would agree that the theoretical gains (such as less
pain, return to work, shorteer hospital stay) are either non-existent,
minimal or of irrelevant value to most patients. This is very different
to gynaecology or gall-bladder surgery, for example, where laparoscopic
surgery has those true benefits.



One factor also ignored is that it is very likely that as a speciality
we cause net harm rather than net gain with these minimally invasive
approaches. There are many patients where there has been complication
directly or indirectly attributable to minimal access approach.
Complications directly or indirectly attributable to primary sternotomy,
that could have been avoided with lesser incisions, are rare unless we
will decide to blame sternotomy for all mediastinal infections we see.



Most published series of minimal access surgery ignore the actual result
of surgery and focus on short-term outcomes - pain, operative mortality,
hospital stay. I suspect if one followed patients up to 1 year we will
find worse outcomes with minimal access approaches, because by
definition we will almost always be performing a less adequate
procedure. In most cases the reduced adequacy is inconsequential but
occasionally it is of major impact. For example we cant seriously
believe that tying down a valve with a knot pusher or robotic arm is
equivalent to a human finger. In my center, as many other academic
centers too I am sure, we do a substantial number of reoperations for
early failures of cardiac surgery done elsewhere (patients operated
within previous year). What we increasingly see is that the majority of
these have been done through minimal access incisions. Most have
technical failures that have been made more likely by the small incsion.
For example we have seen mitral replacements with early paravalvar leak
done for degenerative disease through 6cm incisions and on inspection
several of the sutures are loose, valve repairs where short cuts have
been taken and valves are easily rerepairable via sternotomy, repairable
valves that were replaced, incomplete surgical corrections etc. A very
common feature of these operative reports is that there is a much better
and detailed description of the incision, gagetry used - bypass,
cardioplegic, clamping and exposure gizmos - than there is of the valve
procedure itself, suggesting more thought was going into the exposure
and completing the procedure through a small incision than was going
into the valve procedure itself.



We do offer minimal access surgery in my center, but are careful to
counsel patients that the only difference worth doing this for is the
appearance of the incision and for a patient not concerneed with
location or size of incision we do not recommend it. We tell them that
while there may be secondary gain, those gains are very debatable,
short-lived and of no consequence. We also tell them there are data
suggesting a higher stroke rate with side approaches. We would never
impose a non-sternotomy approach on a patient who is not asking for one.
Doctors who counsel their patients otherwise (that non-sternotomy
approaches are superior to steernotomy) are probably not giving a well
informed consent. We are hopefully advancing the speciality by using
lesser incisions, but as we learn from coronary stenting and
percutaneous valves, reducing invasivenesss, while desirable,
fashionable, and even if the future, is not necessarily superior to
conventional surgery.



Ani

To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] partial sternotomy
Date: Mon, 11 Jan 2010 21:10:54 -0500
From: tdmartin2000 at aol.com
CC:


Prasanna- you know I love you and all my HSF colleagues, but besides
the cosmetic there is absolutely no advantage and in fact makes the
operation harder and higher risk.
Can't wait to hear the responses from that!
Tom






-----Original Message-----
From: Prasanna Simha M <prasannasimha at gmail.com>
To: OpenHeart-L <OpenHeart-L at lists.hsforum.com>
Sent: Mon, Jan 11, 2010 9:21 am
Subject: Re: [HSF] partial sternotomy


There are advantages, ranging from cosmetic to wound healingand
ecreased pain(at least if there is no transverse cut)
rasanna
On Mon, Jan 11, 2010 at 7:45 PM, <tdmartin2000 at aol.com> wrote:

My question to all is WHY?

Tom Martin
U of Florida
Gainesville






-----Original Message-----
From: Prasanna Simha M <prasannasimha at gmail.com>
To: OpenHeart-L <OpenHeart-L at lists.hsforum.com>
Sent: Mon, Jan 11, 2010 8:33 am
Subject: Re: [HSF] partial sternotomy


Axel I do it through lower hemisternotomy. I haven't any problems per
e with it. Others do it through an upper hemisternotomy. I used to do
t via upper hemisternotomy but switched over to lower hemisternotomy
or wound and pain issues. (Others on this list have contrary opinions
rt to this). I find it easier, easy to monitor distention,
efibrillate, deair etc etc especially when you don't have dedicated
EE, defib patches etc etc. Others seem to do it equally well through
pper approach but may have more gizmos at hand that they can use to
o it safely.
rasanna
On Mon, Jan 11, 2010 at 6:06 PM, prof. dr. axel laczkovics
axel.m.laczkovics at ruhr-uni-bochum.de> wrote:
dear all:

among different approaches, we still do the classical way for simple
AVR
with or w/o CABG etc.

the treatment of choice in most of the simple cases is a partial
sternotomy.
but i did not find out yet, if the upper or the lower sternotomy has
better
arguments, advantages, outcomes?

could you be so kind to tell me what you are doing and why?

thx, axel laczkovics
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