Median sternotomy

Cardiac (with median sternotomy) Staphylococci, enteric gram-negative rods Cefazolin... 

Fig. 4.41 Location of surgical incisions for placement of epicardial systems. The common median sternotomy is not shown. (From Belott PH, Reynolds DW. Permanent pacemaker implantation. In Ellenbogen KA, Kay N, Wilkoff BL, eds. Clinical cardiac pacing. Philadelphia WB Saunders, 1995, with permission.)...

The median sternotomy is the most popular approach because it provides optimal exposure and access to the entire heart (94-96). It is used in patients undergoing an open-heart procedure who also require ICD implantation. The incision is weU tolerated and associated with much less patient discomfort. Two large patches may easily be placed extrapericardially (Fig. 4.43). Excellent exposure is achieved as the procedure is generally performed under cardiopulmonary bypass with the lungs deflated. The rate sensing leads are directly screwed to the epicardial surface. The patch electrodes are sutured to the pericardium. 

A limited thoracotomy should be considered if both the superior (implant vein) and inferior (femoral) approaches fail to extract the lead. In 1985, Byrd and associates described a limited surgical approach for extracting chronic pacing leads that were unsuccessfully removed by transvenous techniques (46). A limited thoracotomy with low morbidity has been developed that totally avoids an extensive thoracotomy, as well as median sternotomy. This approach generally has been used as a primary approach in patients with uninfected lead systems that require removal. The transatrial approach allows for removal of leads that are inaccessible by the superior vena cava or inferior vena cava approach. This approach also affords ease of replacement of endocardial lead systems by the same technique. This is why it is most amenable to patients who are not infected. The transatrial approach with a limited thoracotomy has also been used for replacement of endocardial lead systems when all available veins have been obliterated after a superior vena caval or inferior vena caval extraction procedure. 

Brodman R, Fisher JD, Furman S, Johnston DR, Kim SG, Matos JA, Waspe LE. Implantation of automatic cardioverter-defibrillators via median sternotomy. Pacing Clin Electrophysiol 1984 7 1363-9. 

In a non-randomized study, 391 patients who were given aprotinin after median sternotomy for non-bypass surgery were compared with 370 controls postoperative cardiac, renal, neurological, and respiratory complications and hospital mortality were similar in the two groups [20E]. 

After median sternotomy the pericardium is opened in a reversed T-shape fashion and suspended by stay sutures. The heart is examined for evidence of cardiac injury, coronary heart disease and global right and left ventricular contractility. 

After standard median sternotomy, opening and suspension of the pericardium, the typically en-... 

In the first 30 days after cardiac transplantation, primary graft failure accounts for 41% of mortalities, followed by multi-organ system failure (13%) and non-CMV infection (14%) (Taylor et al. 2004). During this period, recipients also face complications related to cardiothoracic surgery and median sternotomy, and post-operative infection (Knisely et al. 1999 Knollmann et al. 2000a Leung 1999). 

Jolles H, Henry DA, Roberson JP, Cole TJ, 8pratt JA (1996) Mediastinitis following median sternotomy CT findings. Radiology 201 463-466... 

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