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Background: In this study, we present our single-center experience in robotically-assisted endoscopic surgery versus conventional median sternotomy approach in patients undergoing cardiac myxoma excision. Methods: Between January 2011 and September 2019, a total of 46 patients (24 males, 22 females; mean age 54.1±12.5 years; range, 25 to 79 years) who had a confirmed diagnosis of isolated cardiac myxoma were included in the study. The patients were divided into two groups as those undergoing robotic-assisted surgery (n=16) and those undergoing conventional median sternotomy (n=30). Clinical characteristics, operative, and postoperative outcomes were compared. Robotic approach to right or left-sided tumors and postoperative pain scores were also analyzed. Results: There was no mortality or major complication. No conversion to sternotomy was needed in robotic procedures. The mean cardiopulmonary bypass and aortic cross-clamp times were significantly shorter in the median sternotomy group (p=0.001 for both). The mean ventilation time and the length of hospital stay were significantly shorter in robotic surgery than sternotomy group (p=0.043 and p=0.048, respectively). The mean amount of postoperative blood loss and transfusion rate were significantly lower in robotic surgery patients (p=0.001 and p=0.022, respectively). The mean postoperative pain scores were significantly lower in patients undergoing robotic surgery (p=0.022). Conclusion: Robotic-assisted endoscopic surgery can be performed safely and effectively for cardiac myxoma excision with shorter hospital stay, less pain, and less amount of blood product use, as well as more favorable cosmetic results compared to conventional median sternotomy.

Background:Isolated coarctation of the aorta can be repaired by either lateral thoracotomy or sternotomy approach with end-to-end anastomosis. Most commonly, neonates with coarctation of the aorta also have hypoplasia of the arch, requiring median sternotomy and extended end-to-side anastomosis with arch augmentation. The aim of this study was to describe our experience as the institution adopted the median sternotomy approach for repair, by reviewing complications, mortality, and reintervention.Methods:Retrospective chart review of 66 patients aged 0–1 year who had arch repair performed by a single surgeon over an 8-year period was performed. Median age at surgery was 22 days (4–232) and median weight was 3.08 kg (1.25–8.0). Forty-one (62%) patients underwent median sternotomy.Results:There was 1 death from a noncardiac cause. Eighteen per cent of our patients were ≤2.5 kg. Vocal cord paresis occurred in 16% of patients under 2.5 kg and 9.5% of patients 2.5 kg or above at the time of surgery. Hypertension at 6-month follow-up was greater in patients under 2.5 kg (44%) than patients 2.5 kg or above (15%). Total surgical reintervention rate was 6%. For patients above 2.5 kg, the surgical reintervention rate was 5.4% and for patients below 2.5 kg, the surgical reintervention rate was 8.3%.Conclusion:We concluded that for neonates with coarctation of the aorta and hypoplastic arch, median sternotomy is a safe surgical approach with low morbidity and mortality with the possible advantage of reduced surgical re-intervention and mortality in the population below 2.5 kg.

Purpose The purpose of this study is to compare short term results of patients undergoing a third generation (HVAD™or HeartMate™ 3) Left Ventricular Assist Device (LVAD) implantation through either minimally-invasive, thoracotomy approach or standard median sternotomy. Methods We prospectively collected data on all patients at our institution that received an LVAD from September 2008 to February 2020. Surgical approach was decided by the implanting surgeon. We used 1:1 propensity score (PS) matching to compare the sternotomy versus thoracotomy groups. A logistic regression model based on 19 explanatory variables was used to estimate the propensity score. Overall survival post-implantation was summarized using Kaplan-Meier curves and compared using the log-rank test. Results A total of 272 patients were included, of whom 194 had sternotomy and 78 had either left thoracotomy and hemi-sternotomy or bilateral thoracotomies. Using PS matching, 128 (64/64) patients were selected. Demographics and operative characteristics were well balanced between groups. Overall, there was a trend towards better survival in thoracotomy group (33.1% vs 66.4%, p=0.06) at 5 years, but higher stroke rate (11% in sternotomy group vs 21% in thoracotomy group, p = 0.035). Following PS-matching, however, there was no difference in early or late mortality (Graph 1) but there was a higher rate of pump exchange in the thoracotomy group (2% vs 9%, p = 0.052). There was no difference in perioperative stroke rates (sternotomy 6% vs thoracotomy 9%), extubation time (2.5 days vs 2.5 days), right ventricular failure (13% vs 14%), renal failure (8% vs 5%) or hospital readmissions (81% vs 88%). Conclusion Minimally invasive LVAD implantation is feasible and safe in the current LVAD era. In a PS matched analysis, patients in the minimally invasive group displayed lower overall mortality, but without reaching statistical significance. Adverse events were similar in both groups.

Mitral valve repair is the standard of care for degenerative mitral valve pathology, as established by the median sternotomy approach. Equivalently excellent results can be achieved by a variety of more minimally invasive approaches depending on institutional experience and preferences. At the Minneapolis Heart Institute®, we have experience with and utilize all approaches to mitral valve repair for degenerative disease including full and hemisternotomy, right thoracotomy, mini-thoracotomy and heart port approaches. We believe that logistic, economic, and anticipated benefit constraints currently limit the application and the robotic technology. Leaflet maneuvers continue to be important in mitral valve repair, but recently we have revisited the concept of simplifying a “complex” repair in the setting of a subset of severe degenerative (Barlow's) disease by utilizing only an oversized mitral valve ring with excellent results. As suggested by others, in the appropriate setting of bileaflet prolaps...

Objective The Cox-Maze IV procedure has been shown to be an effective treatment for atrial fibrillation when performed concomitantly with other operations either via median sternotomy or right minithoracotomy. Few studies have compared these approaches in patients with lone atrial fibrillation. This study examined outcomes with sternotomy versus minithoracotomy in stand-alone Cox-Maze IV procedures at our institution. Methods Between 2002 and 2015, 195 patients underwent stand-alone biatrial Cox-Maze IV. Minithoracotomy was used in 75 patients, sternotomy in 120. Freedom from atrial tachyarrhythmias was ascertained using electrocardiography, Holter, or pacemaker interrogation at 3 to 60 months. Predictors of recurrence were determined using logistic regression. Results Of 23 preoperative variables, the only differences between groups were that minithoracotomy patients had a higher rate of New York Heart Association 3/4 symptoms and a lower rate of previous stroke. Minithoracotomy and sternotomy patients had similar atrial fibrillation duration and type. Minithoracotomy patients had a smaller left atrial diameter (4.5 vs 4.8 cm, P = 0.03). More minithoracotomy patients received a box lesion (73/75 vs 100/120, P = 0.002). Minithoracotomy patients had a shorter hospital stay (7 vs 8 days, P = 0.009) and a similar rate of major complications (3/75 (4%) vs 7/120 (6%), P = 0.74). There were no differences in mortality or freedom from atrial tachyarrhythmias. Predictors of atrial fibrillation recurrence included a preoperative pacemaker, omission of the left atrial roof line, and New York Heart Association 3/4 symptoms. Conclusions Stand-alone Cox-Maze IV via minithoracotomy was as effective as via sternotomy with a shorter hospital stay. A minimally invasive approach is our procedure of choice.

Thoracoscopic subxiphoid approaches, such as the single-port thymectomy (SPT) and dual-port thymectomy (DPT) approaches have been demonstrated to have several advantages compared with the traditional median sternotomy approach or the bilateral or hemilateral video-assisted thoracoscopic (VATS) approach. However, SPT and DPT are technically demanding for novice surgeons since they require precise concomitant manipulation of surgical instruments and the thoracoscope within the same port, without interference. To overcome these limitations, we have developed a new method, termed DPT plus one (DPT+1), to facilitate separation of the surgical access ports and camera port by adding another intercostal port to the DPT approach. Our method is easy and safe not only for simple mediastinal resection but also for extended thymectomy.

Purpose Left ventricular assist devices (LVADs) have become a critical component of heart failure therapy. Many efforts are made to reduce complications and hospital length of stay. Thoracotomy and median sternotomy are both used as surgical approaches. Here, we investigated pain level and opioid use in the peri-operative stage in patients undergoing LVAD implantation via thoracotomy or median sternotomy approach. Methods : We retrospectively reviewed 55 patients who underwent left ventricular assist device (LVAD) implantation between 2017-2020. Of these, 41 (75%) LVADs were implanted via median sternotomy approach and 14 (25%) LVADs were implanted via thoracotomy. Maximum pain score at day 3 and 7 post-op, at discharge and first follow-up visit were evaluated for both groups. In addition, amount of oxycodone given in the peri-operative period in both groups was investigated. Results Both groups were similar in age and gender distribution ( Table 1 ). Heartmate III® was the main VAD type implanted in the sternotomy group (76%; n=31) while HVAD Heartware® was in the thoracotomy group (86%; n=12). There was no difference in the mean length of ICU stay or hospital stay between the groups (both p>0.05; Table 1 ). While there was a decrease in median pain score from day 3 post-op to first visit follow-up in both groups, the pain score was comparable between the two groups at day 3 and 7 post-op, at discharge and first-follow-up ( Table 1 ). Also, we did not find a significant difference in oxycodone use between thoracotomy and median sternotomy groups. Conclusion Both thoracotomy and median sternotomy approach resulted in similar peri-operative pain level and opioid use in patients undergoing LVAD implantation.

Background: The standard approach in treating cardiac myxoma is the median full sternotomy. With the evolution of surgical techniques, the right minithoracotomy approach has emerged as an alternative method. Since few studies have been published assessing the right minithoracotomy approach, we performed a retrospective study to compare the clinical outcomes of the right minithoracotomy approach with those of the sternotomy approach. Methods: From January 2005 to December 2014, 203 patients underwent resection of a cardiac myxoma. Patients with preexisting cardiac problems were excluded from this study. 146 patients were enrolled in this study; 83 patients were treated using a median sternotomy and 63 patients were treated using a right minithoracotomy. Results: No early mortalities were recorded in either group. Although the cardiopulmonary bypass time and aorta cross-clamp time were significantly shorter in the sternotomy group (p＜0.001 and p=0.005), postoperative blood transfusions and arrhythmia events were significantly less common in the thoracotomy group (p=0.004 and p=0.025, respectively). No significant differences were found in the duration of the hospital stay, postoperative intubation time, the duration of the intensive care unit stay, and recurrence. Conclusion: The minimally invasive right minithoracotomy approach is a good alternative method for treating cardiac myxoma because it was found to be associated with a lower incidence of postoperative complications and a shorter postoperative recovery period.

The choice of optimal operative access technique for mechanical circulatory support device implantation ensures successful postoperative outcomes. In this study, we retrospectively evaluated the median sternotomy and lateral thoracotomy incisions for placement of the Cleveland Clinic continuous-flow total artificial heart (CFTAH) in a bovine model. The CFTAH was implanted in 17 calves (Jersey calves; weight range, 77.0-93.9 kg) through a median sternotomy (n = 9) or right thoracotomy (n = 8) for elective chronic implantation periods of 14, 30, or 90 days. Similar preoperative preparation, surgical techniques, and postoperative care were employed. Implantation of the CFTAH was successfully performed in all cases. Both methods provided excellent surgical field visualization. After device connection, however, the median sternotomy approach provided better visualization of the anastomoses and surgical lines for hemostasis confirmation and repair due to easier device displacement, which is severely limited following right thoracotomy. All four animals sacrificed after completion of the planned durations (up to 90 days) were operated through full median sternotomy. Our data demonstrate that both approaches provide excellent initial field visualization. Full median sternotomy provides larger viewing angles at the anastomotic suture line after device connection to inflow and outflow ports.

Because of the extreme donor shortage in Japan, waiting times for heart transplantation exceed 2 years. Since 1980s in Japan, device availability has also been an issue, with only a few paracorporeal ventricular assist devices (VADs) available as a bridge to transplantation or recovery. However, two implantable VADs became commercially available in 2011. Given these constraints in our healthcare system, we report a relatively rare case of bridge-to-bridge use of an implanted EVAHEART after having used a paracorporeal AB-5000 support for an extended period of time. We successfully employed a combined left thoracotomy and median sternotomy approach as a conversion technique.

A three-year-old child developed a large tracheo-oesophageal fistula secondary to a button battery being lodged in the upper oesophagus for 36 hours. The diagnosis was confirmed with a contrast swallow. Operative access was gained through a combined right cervical incision and complete median sternotomy. Repair of the fistula required a segmental resection of both the trachea and oesophagus followed by primary anastomosis.

Background Minimally invasive surgery has become the standard approach for several cardiac diseases. In this retrospective study, we compared right anterolateral minithoracotomy (RALT) with standard median sternotomy (SMS) for resection of left atrial myxoma (LAM). Materials and Methods From January 2009 to June 2015, the clinical data of patients who underwent RALT (n = 30) and SMS (n = 36) for resection of LAM in our hospital were collected. The preoperative clinical data and operative results were compared between the two groups. Results There were no significant differences in aortic cross-clamp and cardiopulmonary bypass time between the two groups. The total incision length was significantly shorter in RALT group compared with SMS group (p Conclusion RALT approach for LAM resection can be performed safely with favorable cosmetic outcome, accepted clinical results, and lower cost. It should be considered as a promising alternative to SMS and merit additional study.

Objective The Blalock–Taussig (BT) shunt is an excellent palliative procedure for cyanotic congenital heart defects. We reviewed two techniques of performing the BT shunt, median sternotomy and thoracotomy, in relation to morbidity and mortality. Methods Forty-five modified BT shunts in 41 patients, mean age 93 days (1–1045 days), were performed between January 2002 and October 2004. Twenty-four (53.3%) shunts in 21 (51.2%) patients were performed through thoracotomy and 21 (46.7%) shunts in 20 (48.8%) patients through median sternotomy. One surgeon preferred thoracotomy and the other sternotomy approach irrespective of age/weight or elective/emergency. Thirty-eight (84.4%) cases underwent elective operation and 7 (15.6%) cases were operated as emergencies. In both groups the most frequent diagnosis was complex Tetralogy of Fallot. Results Postoperative oxygen saturation was same in both groups and there were no significant complications in either group. Patients undergoing BT shunt via median sternotomy approach had longer duration of ventilation (mean 183h vs. 53h, P P P P Conclusions Median sternotomy approach to performing BT shunt seems to carry a higher morbidity than thoracotomy. We recommend a large case series study and longer follow up.

OBJECTIVES Lower mini-sternotomy represents a minimally invasive surgical technique that has been utilized for the repair of a wide variety of congenital heart defects with excellent surgical and cosmetic outcomes. However, clinical improvements provided for this technique beyond cosmetic results are controversial. The aim of our study is to report our results with lower mini-sternotomy for the repair of congenital heart malformations and compare them with a matched group with a full median sternotomy approach. METHODS From 2010 through 2013, 105 consecutive congenital patients (81 paediatric) underwent lower mini-sternotomy at our centre (Group 1). We analysed in-hospital and follow-up outcomes, and compare them with an age-sex-diagnosis-type of surgery-matched group (Group 2). Both groups were managed following the same clinical protocols. RESULTS In Group 1, age at the time of surgery was 12 ± 17 years (range from 0.2 to 64.6 years). In this group, 81 patients were paediatric and 62 were female. Operative techniques were atrial septal defect (n = 72), ventricular septal defect (n = 24) and atrioventricular canal repairs (n = 9). There were no deaths or major in-hospital complications. Two adult patients required conversion to full median sternotomy. For a medium follow-up of 1.5 years (range from 1 month to 5 years), there were no deaths, reinterventions or reoperations and no significant residual defects were found. Compared with Group 2, patients in Group 1 had longer cardiopulmonary bypass times (58.71 ± 19.08 vs 45.39 ± 20.45, P < 0.001) and cross-clamp times (32.75 ± 13.11 vs 23.22 ± 13.93, P < 0.001), higher rate of early extubation (96 vs 85%, P = 0.018) and lower rate of postoperative complications (11.6 vs 22.3%, P = 0.034). CONCLUSIONS At our centre, lower mini-sternotomy represents a safe alternative for the repair of congenital heart defects in paediatric and adult populations. Cardiopulmonary bypass and cross-clamp times were longer in the mini-sternotomy group. However, these patients showed earlier extubation and less postoperative complications when compared with patients with a full sternotomy approach. Combined with improved cosmetic outcomes, lower mini-sternotomy could represent the technique of choice for these populations.

e20005 Background: Anterior mediastinal masses are a diverse group of tumors generally presenting as compressive symptoms. Larger masses require open surgical approaches including median sternotomy or sterno-thoracotomy. In this study we analyzed the surgical and pathological outcomes of large anterior mediastinal masses resected through sternotomy approach. Methods: Data of 16 patients with anterior mediastinal masses ( > 10 cms) treated surgically was analyzed retrospectively. All the patients were evaluated preoperatively with MRI, CT guided biopsy and pulmonary function test followed by exploration through median sternotomy approach with/without cardiac bypass (through femoral access). Adjuvant chemo-radiation was used according to histopathological features. Results: A total of 10 male and 6 females with median age 42 years (range: 6-62) underwent resection. Three patients received neoadjuvant chemotherapy and the mean tumor size was 12.2 cms. Histopathologies included mature teratomas/dermoids (4), thymic carcinoma (3), nerve sheath tumors (3), malignant germ cell tumors (3), synovial sarcoma (1) primary mediastinal goiter (1) and inflammatory pseudo tumor (1). There was no postoperative mortality and two patients required cardiac bypass. Bovine pericardium was used in two patients for the loss of large are of pericardium. One patient required biograft for replacement of resected superior vena cava. Major morbidities included prolonged ventilation and intrathoracic collection in two patients. All the patients were disease free after a median follow up of 14 months. Conclusions: Large anterior mediastinal masses are challenging surgically. An aggressive surgical approach through median sternotomy in association with cardiac bypass helps in complete resection and may lead to optimal results.

Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.

Atrial septal defect (ASD) is the most common congenital cardiac disorder requiring intervention. Nowadays, most defects are closed percutaneously, but there will always remain defects that have to be closed surgically. In the past, techniques other than the standard median sternotomy approach have been advocated such as axial thoracotomy, lateral thoracotomy and limited sternotomy. In the last years, an increasing number of techniques of video-assisted mini-thoracotomy or full thoracoscopic methods including robotic-assisted operations have been described. Here, we describe and illustrate our experience with a video-assisted approach using femoral cannulation and a small thoracotomy for closure of an ASD. With this method, it is easy to perform a (additional) tricuspid valve operation at the same time, should this be indicated.

Repair of scimitar syndrome presenting in infancy involves either tunneling or reimplantation of the anomalous vein to the left atrium and may be fraught with serious complications such as thrombosis and secondary pulmonary infarction necessitating pneumonectomy. The authors present the case of a severely symptomatic infant with scimitar syndrome, managed initially with closure of an atrial septal defect in the hope of avoiding a repair with considerable risk of scimitar vein thrombosis and pulmonary infarction. Despite initial clinical improvement, subsequent rapid development of spontaneous massive emphysematous degeneration of the right lung necessitated emergency pneumonectomy, which was accomplished via the median sternotomy approach.

We report the usefulness of a median sternotomy approach for the surgical treatment of residual aortic gradients or recoarctation and aortic aneurysms. This series confirms that excellent surgical results can be obtained in this technically challenging group of patients needing postcoarctation repair.

We describe herein the case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM). Although most reports describe cervical or thoracotomy approaches, our experience strongly suggests that median sternotomy is a satisfactory alternative approach for treatment of this disease.

Although pulmonary resections have been performed through median sternotomy, this approach for extrapleural pneumonectomy in the management of malignant pleural mesothelioma has not been described. We assessed the feasibility of a median sternotomy approach as an alternative to thoracotomy in right-sided resections. Over a 15-month period, this approach was attempted in 10 cases. In 7 of them, the entire procedure was completed without additional thoracotomy access. There were no postoperative deaths in this group. At median follow-up of 8 months, we have not encountered tumor progression in the scars.

In recent years, there has been much interest in performing coronary artery bypass graft (CABG) surgery without the aid of cardiopulmonary bypass (CPB). Initial efforts focused on "minimally invasive" direct coronary artery bypass, wherein the left anterior descending artery is bypassed with an in situ left internal mammary artery graft through a small left anterior thoracotomy. A more widely adopted approach however, is off-pump CABG (OPCAB), in which CABG surgery is performed on one or more vessels through the usual median sternotomy approach without the aid of CPB. This article reviews the differences in the anesthetic considerations of OPCAB compared to conventional CABG using CPB.

Background . Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus. Methods . From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy. Results . Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms. Conclusions . Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.

An experimental study was conducted in 12 dogs to evaluate the technical feasibility of using the 8th and 9th intercostal arteries as pedicled grafts for myocardial revascularization. In phase 1 (n = 4), the technique to harvest the intercostal artery as a pedicled graft posteriorly based on the thoracic aorta was developed. In phase 2 (n = 4), the sternotomy approach was compared to posterolateral thoracotomy for access. Pedicles were routed to various coronary arteries via a pericardial window. In phase 3 (n = 4), evaluation was confined to the left 8th and 9th pedicles via median sternotomy approach, as this is more clinically applicable. Blood flows and external diameters were measured. Mid sternotomy approach to the 8th and 9th intercostal arteries on both the right and left was feasible and technically adequate grafts were obtainable. These pedicled grafts reached the branches of both the left circumflex and right coronary artery. Mean blood flows in the left 8th and 9th intercostal artery grafts were 25+/-2.58 and 27+/-2.1 mL/min with mean external diameters of 0.44+/-0.027 and 0.48+/-0.028 mm, respectively, and a mean body weight of 25 kg. We conclude that the 8th and 9th intercostal arteries can technically be harvested as pedicled grafts via median sternotomy and can be used to revascularize the left circumflex coronary system.

Background: Because placement of a coronary sinuslead is not alwayspossible for anatomical or technical reasons, surgical implantation of anepicardial LV lead is occasionally indicated. There are two different surgical approaches: a median sternotomyand a left-lateral mini thoracotomy, and bothsuture and screw types of myocardial lead have unique specification. Methods: The manipulation performance was compared between the two types of lead in 57 patients who underwent surgical implantation of anLV epicardial lead from 2000 to 2010. Serial changes in the LV pacing threshold were examinedin 10 patients (suture and screw type in 5 patients each) at implantation, 1 week, and 3 months after implantation. Results: The median sternotomy approach allowed the suture type lead to be implanted easily and freely on any desired site on the high lateral LV wall, because of the widely opened operating field. Meanwhile the left-lateral mini thoracotomyapproach provided a limited field of the high lateral LV and allowed only the screw type lead to be implanted. There was no significant serial change in the pacing threshold in both suture and screw types and no significant difference between the types (suture type: 1.56±1.2 V, 1.42±1.0 V, 1.12±0.8 V, screw type: 1.56±1.3 V, 1.22±0.5 V, 1.36±0.4 V, at implantation, 1 week, and 3 months after implantation, respectively). Conclusion: The suture type is recommended in the surgery through a median sternotomy and the screw typelead through a left-lateral mini thoracotomy.

We read with interest the article ‘Manubriotomy versus median sternotomy in thymectomy for myasthenia gravis. Evaluation of pulmonary status’ written by Granetzny et al. [1]. The authors are to be congratulated, especially for the detailed analysis of the respiratory changes in patients after a thymectomy. However, several points regarding the study should be raised. Postoperative respiratory insufficiency rate with the use of a ventilator in patients of the complete sternotomy group was excessively high (15.4%) despite relatively mild myasthenia (only 1/26 patients in class I and IIa, according to MGFA classification) and the young age of most of patients (mean: 24.6 years). The respiratory insufficiency might have been a result of incorrect postoperative medication with intravenous delivery of neostygmine soon after the operation. It must be stressed that all aniticholinesterase inhibitors should be withdrawn after the operation until the symptoms of myasthenia recur, which may take several hours or days. Delivery of aniticholinesterase inhibitors too soon after an operation may be the cause of a cholinergic crisis, which is very difficult to distinguish from a myasthenic crisis in clinical practice. The overall postoperative morbidity in the complete sternotomy group was very high (15.4% respiratory insufficiency and 26.9% other complications), despite quite limited invasiveness of the operative approach (the mediastinal pleura was not intentionally opened during the dissection and there is no mention about dissection of perithymic fat in the neck or epiphrenic fat pads). The authors statement that “the maximal resection of the thymus gland and ectopic tissue was deemed mandatory for surgical success and improvement of the disease, and every effort was done to achieve it” is therefore hardly justifiable. Obviously, the technique used by Granetzny et al. is much less radical than techniques described by Jaretzki and Bulkley [2–4]. Also, the conclusion that “thymectomy through manubriotomy, which allows extensive removal of ectopic thymic tissue in addition to the thymus” is not supported by any results in the study. The results reported by our team [5] showed that postoperative morbidity in a complete sternotomy approach for a thymectomy was similar to an upper median sternotomy approach (equivalent of manubriotomy) regarding respiratory insufficiency (4 and 3%, respectively) and overall morbidity (12 and 10%, respectively). In addition, we have shown that the use of an extended thymectomy performed by a complete sternotomy approach resulted in significantly higher complete remission rates in comparison to a basic thymectomy performed through an upper median sternotomy (46.6 vs 15% after 4-year follow-up; PZ0.0007). In conclusion, (1) postoperative morbidity after a thymectomy through a complete sternotomy reported by Granetzny et al. is excessively high which leads the authors to the exaggeration of invasiveness of this procedure and (2) the statement that a manubriotomy approach enables equally extensive dissection as a complete sternotomy is not supported by the results of the study. Despite the criticism of our remarks, we appreciate the contribution of Granetzny and colleagues very highly and we look forward for their further studies on the operative treatment of myasthenia gravis.

The intrapericardial placement of implantable cardioverter defibrillator patches has been associated with a variety of complications due to the patch-epicardial interface. Extrapericardial placement of defibrillator patches minimizes these problems. We describe a simple and reproducible technique to achieve this goal whenever a median sternotomy approach is used.

The median sternotomy incision has become the routine approach for most cardiac surgical procedures. This generally gives a poor cosmetic result. In certain patients, particularly those who are asymptomatic and undergoing short, low-risk procedures, cosmetic considerations are of relatively greater importance. We describe a transverse skin incision which gives adequate exposure for the median sternotomy. It has been used successfully in 40 female patients. This technique provides a cosmetically acceptable incision for the median sternotomy approach.

The median sternotomy approach to intracardiac operations may be associated with damage to the brachial plexus similar to that reported with other types of operations. In 5 patients treated at the University of Michigan Hospital, varying degrees of upper extremity paralysis resulted from excessive spread of the retractors in an attempt to improve exposure of the heart.

A median sternotomy incision was employed in 73 cases of pulmonary surgery instead of posterolateral thoracotomy. An anterior mediastinal approach was used in three groups of patients: group 1 patients (47 cases) underwent simultaneous bilateral surgery for pulmonary disorders on both sides, in group 2 patients (15 cases), this approach was selected to facilitate surgery on the involved mediastinal structures, and group 3 patients (11 cases) had left lung cancer with extensive dissection of lymph nodes done via median sternotomy, as well as routine dissection of nodes by posterolateral thoracotomy. A median sternotomy approach for pulmonary surgery provided an excellent operative field, and most patients experienced less postoperative pain and a quicker recovery. The surgical indications for this approach, the surgical procedure, the results, and the advantages and disadvantages of using a median sternotomy incision are discussed.

WHILE MEDIAN sternotomy is routinely used as the optimal approach for the repair of many cardiac defects, postoperative drainage even when the pericardium is left widely open may be less than adequate.1Consequently, the correction of certain lesions which seem predisposed to more than the usual blood loss after apparent restoration of the clotting mechanism and adequate hemostasis, are managed by also opening the pleural reflection on the right side. This allows for continuous decompression of the pericardial cavity into the right pleural cavity. However, the potential for troublesome postoperative bleeding from the anterior mediastinum, and particularly from sternal fractures produced during adequate exposure of the heart through the median sternotomy approach, is sometimes not ap preciated and may be overlooked at the time of wound closure. The tendency for bleeding to persist from retrosternal tissue planes is compounded by the continuous motion of the heart when the pericardium

A median sternotomy approach was used for closure of patent ductus arteriosus associated with a hypoplastic right lung. The anterior approach to the left ductus is indicated if left thoracotomy is contraindicated.