[Experiences of the approaches to heart for a patient with a tracheostoma]

The performance of open heart surgery in a patient with a tracheostoma can present difficult problems, including postoperative mediastinitis and inadequate operative exposure. Recently, we experienced two cases in which tracheostomy had been done preoperatively due to heart failure and reported the satisfactory results in this paper. Case 1; A 59-year-old woman who had mitral stenosis and massive regurgitation received mitral valve replacement and left atrial raphy. The approach to heart was performed in according to the following. A transverse submammary skin incision was made from right anterior axillar line to left mammary line and then a bilateral thoracotomy was made at the fourth intercostal space. Case 2; A 73-year-old man who had old myocardial infarction and postinfarction angina received coronary artery bypassgrafting to right coronary artery and left anterior descending branch, using saphenous vein grafts. A skin incision was placed at the second intercostal space in the fashion of "collar skin incision" and then made from the center of collar skin incision to the xiphoid process. The sternum was transected at the second intercostal space and divided longitudinally to the xiphoid process. These two approaches provided the adequate operative field. The cannulation of the ascending aorta, the superior vena cava and the inferior vena cava presented no difficulty and the operative procedure could be performed easily in a routine manner. We think that in a case of open heart surgery of a patient with a tracheostoma the approach in which the skin incision is distant from the area of a tracheostoma and no dissection near a tracheostoma is necessary have to be selected in order to decrease the risk of postoperative wound infection and mediastinitis.