Not splitting the chest!
The late Dr Louis Cohen was a delightful man, and an incredibly caring cardiologist with a passion for squash, who was very well known at the University of Chicago for his dedication to his patients. A large, luxuriant and very prominent white beard graced his face. As a fortunate collaborator of his, I was the beneficiary of many entertaining stories and some interesting, high profile Chicago faculty members as patients. His refrain about the sternum - "every one of these white hair in my beard is a reminder of a sternal wound problem in one of my patients". It was a gross exaggeration, but you get the idea. This wonderful access incision, the sternotomy has been plagued over the years with a bad reputation. Some of the negatives -
1. A big bone-breaking incision
2. Issues with pain and limitation afterwards
3. Problems with slow healing and wound infections.
4. Restrictions in terms of activity.
5. Sternal dehiscence and/or infections of the sternum & underlying structures.
The impetus to minimize these potential complications have been two-fold -
Avoid the sternum if possible
If the sternum needs to be split, the closure can be helped along with plates and screws (as I mentioned in a previous post).
Lets imagine these alternate approaches -
Less invasive approaches which include
3. Percutaneous, trans-catheter approaches.
4. Robotic cardiac surgery
5. Hybrid approaches - which include a combination of percutaneous and less invasive surgical procedures.
The growth in percutaneous, trans-catheter approaches have been remarkable in many ways. The primary driver for growth has been the avoidance of a big, bone-breaking sternotomy or "cracking of the chest". Many of these percutaneous strategies have been able to overcome sub-optimal medium and long-term outcomes, mainly because they preclude the need for a sternotomy.
We can through each of these alternate approaches to a sternotomy in detail - in the next few blog posts.