alexa
Reach Us +44-1647-403003
Right Parasternal Cardiac Surgery after Radical Treatment of Left Breast Cancer | OMICS International
ISSN: 2329-9517
Journal of Cardiovascular Diseases & Diagnosis
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Right Parasternal Cardiac Surgery after Radical Treatment of Left Breast Cancer

Akimasa Morisaki*, Koji Hattori, Yasuyuki Kato, Manabu Motoki, Yosuke Takahashi, Shinsuke Nishimura and Toshihiko Shibata
Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan
Corresponding Author : Akimasa Morisaki
Department of Cardiovascular Surgery
Osaka City General Hospital
2-13-22 Miyakojima-hondori
Miyakojimaku, Osaka 534-0021, Japan
Tel: +81-6-6929-1221
Fax: +81-6-6929-0623
E-mail: [email protected]
Received December 23, 2013; Accepted February 10, 2014; Published February 16, 2014
Citation: Morisaki A, Hattori K, Kato Y, Motoki M, Takahashi Y, et al. (2014) Right Parasternal Cardiac Surgery after Radical Treatment of Left Breast Cancer. J Cardiovasc Dis Diagn 2:146. doi: 10.4172/2329-9517.1000146
Copyright: © 2014 Morisaki A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Related article at
DownloadPubmed DownloadScholar Google

Visit for more related articles at Journal of Cardiovascular Diseases & Diagnosis

Abstract

A 74-year-old woman required surgical treatment of severe aortic valve stenosis and two-vessel coronary artery disease consisted of a significant stenosis of the left anterior descending branch and right coronary ostium. She had previously undergone radical mastectomy and radiation therapy for left breast cancer. Severe dermal sclerosis and subcutaneous tissue defect at the chest midline, which would cause poor wound healing because of insufficient blood flow, precluded conventional median sternotomy and a left mini-thoracotomy. Therefore, we selected a hybrid treatment approach using a combination of surgery and percutaneous coronary intervention. We performed aortic valve replacement and coronary bypass grafting to the right coronary artery using a right parasternal approach followed by percutaneous coronary intervention of the left anterior descending artery on postoperative day 13. Wound healing was quite satisfactory

Keywords
Aortic valve replacement; Breast cancer; Coronary artery bypass grafting; Right parasternal approach; minimally invasive surgery
Introduction
The use of a right parasternal approach for minimally invasive cardiac surgery has been reported since 1996 [1]. This approach results in a cosmetically acceptable wound and reduced bleeding and infection and, in particular, prevents the disadvantages of median sternotomy [1-4]. We report on a patient who underwent aortic valve replacement and Coronary Artery Bypass Grafting (CABG) via a right parasternal approach. Nearly 30 years earlier, radical treatment of left breast cancer had left the patient with severe dermal sclerosis and an extensive subcutaneous tissue defect; thus, poor wound healing in this area precluded median sternotomy.
Case
A 74-year-old woman suffered from congestive heart failure with dyspnea on exertion due to severe aortic valve stenosis, for which she was indicated for surgical intervention and referred to our facility. At 46 years of age, she had undergone Halsted radical mastectomy and radiation therapy for left breast cancer. This resulted in a massive subcutaneous tissue defect and a severe dermal sclerosis over the sternum onthe left thorax (Figure 1). Chest X-ray revealed cardiomegaly with protrusion of a left ventricular shadow, slight pulmonary congestion, and a hyper lucent left lung. Echocardiography revealed severe aortic valve stenosis with aortic valve effective orifice area of 0.64 cm2, peak velocity of 4.0 m/s, and peak pressure gradient of 64 mmHg accompanied by moderate aortic regurgitation. Left ventricular function was maintained, with an ejection fraction of 67%. Additionally, coronary angiography revealed significant stenosis of the left anterior descending branch (#7) and right coronary ostium (#1), which would require concomitant surgical treatment. A massive subcutaneous tissue defect of the central and left thorax seen on Computed Tomography (CT) (Figure 2) would prohibit conventional median sternotomy because of poor wound healing due to insufficient blood flow. Thus, we considered a right parasternal approach for aortic valve replacement and only bypass grafting to the right coronary artery. Because the right parasternal approach did not allow access for left CABG, percutaneous coronary intervention of the left anterior descending artery was planned for soon after the operation.
After induction of anesthesia and left double-lumen endotracheal tube ventilation, a Swan-Ganz catheter with a pacing lead was inserted and defibrillation pads were placed on the right and left chest before sterile draping. A 10-cm right parasternal skin incision was made. The right pectoralis major muscle was split at the level of the 3rd and 4th intercostal spaces and a muscle flap created. The right internal thoracic artery was then doubly ligated, and the 3rd and 4th costal cartilages were cut and bent into the left thoracic cavity without removal of the ribs. We also cut the 5th costal cartilage to get better exposure to perform the CABG. After systemic heparinization, cardiopulmonary bypass was established with an 18-Fr arterial cannula to the right femoral artery and a 25-Fr venous cannula to the right atrium through the right femoral vein. Vacuum-assisted venous drainage was applied. To ensure sufficient venous drainage, we also inserted a venous cannula into the superior vena cava. During cardiopulmonary bypass, a nonpulsatile perfusion flow of over 2.3 L/min/m2 was maintained under mild systemic hypothermia. After aortic cross-clamping, identical cold blood cardioplegia was administered first through the aortic root, then intermittently in retrograde fashion. The operative field was flooded with CO2. Through a partial transverse aortotomy, the degenerative aortic valve cups were excised and aortic valve replacement performed, using non-everting mattress sutures to secure a mechanical valve (St. Jude Medical Regent™ 17 mm, St. Jude Medical, Inc., Minnetonka, MN, USA). We then performed CABG with a saphenous vein graft to the #2 branch of the right coronary artery. After uneventful weaning from cardiopulmonary bypass, transesophageal echocardiography showed no paravalvular leakage of the aortic valve. An expanded Polytetrafluoroethylene (PTFE) sheet (GORE® PRECLUDE® Pericardial Membrane; W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) was placed under the ribs. After closing the ribs, a continuous-localanesthesia tube was placed under the pectoralis major muscle. The patient was extubated 8 hours after the operation and discharged from the intensive care unit on postoperative day 1. On postoperative day 13, she received percutaneous coronary intervention using a drug-eluting stent to the left anterior descending artery, and coronary angiography revealed a patent bypass graft. Postoperative echocardiography showed aortic artificial valve peak velocity of 2.8m/s and peak pressure gradient of 32 mmHg with an ejection fraction of 64% and no ventricular asynergy. The patient was doing well and discharged without wound complications on postoperative day 16.
Discussion
The present case demonstrates that the right parasternal approach facilitated good wound healing in a patient who had undergone radical mastectomy and radiation therapy for left breast cancer.
The right parasternal approach for aortic valve surgery accompanied by CABG to the right coronary artery is an alternative method for patients with valvular and right coronary arterial disease who are not suitable for median sternotomy. Weinschelbaum et al. [2] reported that valve operations with concomitant proximal right CABG could be accomplished through the same incision as a singlevalve operation via a right parasternal approach with cuts to the 3rd and 4th costal cartilages. Our patient, however, required an additional 5th costal cartilage cut for the proximal right CABG because of caudal displacement of the heart with aging. Furthermore, other authors have reported on aortic valve surgery through a right parasternal approach accompanied by left CABG via an additional left mini-thoracotomy in patients requiring concomitant left CABG [2,3]. However, in the present case, a left mini-thoracotomy could not be performed because of a severe left thoracic subcutaneous tissue defect resulting from radical treatment for left breast cancer. Therefore, we selected a hybrid treatment approach using a combination of surgery and percutaneous coronary intervention. With this strategy we were able to achieve both an improved prognosis and satisfactory wound healing for this patient.
Disadvantages of the right parasternal approach may include lung hernia and flail chest, which may require surgical treatment and contribute to poor wound healing [4,5]. Cosgrove and Sabik [1] first reported on the parasternal approach for aortic valve replacement with detachment of the 3rd and 4th ribs; however, Cosgrove et al. [4] reported a bulging of the chest wall in the majority of such cases. Minale et al. [3] reported that by avoiding rib resection, the right parasternal approach prevented flail chest. We achieved preservation of the anatomical integrity of the chest wall using the same method by placing an expanded PTFE sheet under the ribs. Preservation of thoracic cage, without the need for rib detachment or reconstruction of the pleura, may prevent these disadvantages.
Conclusion
We conclude that the right parasternal approach can be used to perform aortic valve replacement and CABG to the right coronary artery when median sternotomy is contraindicated.
References





 

Figures at a glance

image   image
Figure 1   Figure 2
Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Article Usage

  • Total views: 12907
  • [From(publication date):
    March-2014 - Jan 16, 2019]
  • Breakdown by view type
  • HTML page views : 9093
  • PDF downloads : 3814
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2019-20
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri and Aquaculture Journals

Dr. Krish

[email protected]

+1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

ankara escort

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

pendik escort

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2019 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version