Is resternotomy in cardiac surgery still a problem?☆

Abstract

Multiple factors contribute to the growing number of reoperations for congenital and acquired cardiovascular diseases in the United States. Although the hazards are well-recognized, the health economic burden of resternotomy (RS) remains unclear and may be difficult to quantify. Contrary to published studies citing low frequencies of catastrophic hemorrhage and mortality, survey responses from practicing surgeons disclose higher rates of complications. Safety strategies in cardiac reoperation have generally involved efforts to maximize visualization during dissection, specialized surgical maneuvers and instrumentation, customized methods for establishing extracorporeal circulation, and techniques to prevent or avoid retrosternal adhesions. Yet, the relative cost-effectiveness of these strategies is largely unexplored. With the ongoing constraints in healthcare budgets, differentiating the value of existing and future approaches in terms of relative clinical benefits, costs, and impact on resource utilization will become increasingly important. We reviewed the relevant published literature in order to survey the morbidity and resource utilization associated with RS in cardiac reoperation and to identify key issues relevant for future studies.

Off-pump hepatic to azygos connection via thoracotomy for relief of fistulas after a Kawashima procedure: Ten-year results

“…19 The risks of a repeat median sternotomy in the congenital population are mainly related to possible reentry injuries. 20,21 Although the use of pericardial substitutes can reduce retrosternal adhesions, the risk of injuries is not negligible.…”

“…20 In our study, we perform the surgical connection of the hepatic to the azygos vein with an off-pump technique through a lateral thoracotomy. In our series, there was no need for conversion to cardiopulmonary bypass or median sternotomy.…”

Combined use of barrier methods to prevent pericardial adhesions: Is it always better?

“…Although the increased risk of fatal cardiac trauma can be counterbalanced using a meticulous surgical technique, increased operation times and transfusion requirements increase the costs. In a review examining burden caused by repeated sternotomy, Morales et al [20] reported that the published evidence suggested using certain safety measures in specific clinical scenarios might assist in optimizing clinical outcomes and cost-effectiveness.…”

Using the reciprocating saw for resternotomy

“…There was no mortality that could be attributed to sternal re-entry, and this low injury rate compares well with the rates found in previously published reports. [1][2][3][4] Morales et al [5] examined 12 retrospective studies and found a 0.5-3.6% incidence of catastrophic hemorrhage. They also noted a discrepancy between the survey findings and published injury rates, which likely reflects the underreporting of resternotomies related to injuries in the literature.…”

“…An injury to the heart, great vessels, or previously implanted patent coronary bypass grafts can lead to massive hemorrhage and/or myocardial ischemia and infarction. [1][2][3][4][5] Given these potential risks, many techniques have been described to increase the safety of sternal re-entry. Most of the published reports, however, share a common view that an oscillating saw is preferable to ensure a safe procedure.…”