Elective Primary or Secondary Delayed Sternal Closure Improves Outcome in Severely Compromised Patients
20 November 2016
10 January 2017
17 March 2017 (eFirst)
Background Delayed sternal closure (DSC) in patients with severely compromised preoperative hemodynamics can be helpful as the chest sometimes cannot be able to contain both lungs and heart. We report our experience to evaluate the midterm results of this strategy in an adult population.
Materials and Methods From May 2009 till July 2015, 33 patients had DSC as first treatment of severe hemodynamic deterioration after cardiac surgery. Surgical procedures were valvular (9.27%) or coronary artery bypass grafting + others (24.73%). Stepwise logistic regression (SLR) showed that patients with lower ejection fraction, dilated right ventricle, and severe pulmonary hypertension were more likely to need DSC. Patients were divided in two groups: group A (n = 17), when the sternum was reopened before any hemodynamic collapse, or was never closed, and group B (n = 16), when the sternum was reopened after hemodynamic collapse.
Results Inhospital mortality was 39% (n = 13), 18% in group A and 62% in group B (p < 0.0001). In 28 patients where the sternum was reopened, cardiac index increased from 1.7 (1.6, 1.9) L/m2 to 2.8 (2.4, 3) L/m2, p < 0.0001. The sternum was closed in 28 patients (85%), 94% in group A and 75% in group B (p = 0.13), after a median of 4 (2.5) days. SLR showed that only group B (p < 0.0001) was a risk factor for early death. Two-year survival was 48 ± 9%, higher in group A (71 ± 13) than in group B (25 ± 11), p < 0.0001. Cox's analysis showed that group B (p < 0.0001) and redo (p < 0.0001) were risk factors for lower survival.
Conclusion Elective DSC represents a useful strategy in severely compromised patients, entailing an improvement of hemodynamics and a higher survival.
- 1 Riahi M, Tomatis LA, Schlosser RJ, Bertolozzi E, Johnston DW. Cardiac compression due to closure of the median sternotomy in open heart surgery. Chest 1975; 67 (1) 113-114
- 2 Lancellotti P, Moura L, Pierard LA , et al; European Association of Echocardiography. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2010; 11 (4) 307-332
- 3 Nishimura RA, Otto CM, Bonow RO , et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation 2014; 129: 2440-2492
- 4 Thyagarajan GK, Cobanoglu A. Temporary stenting of the sternum after difficult cardiac operations. Ann Thorac Surg 1997; 64 (5) 1504-1505
- 5 Gielchinsky I, Parsonnet V, Krishnan B, Silidker M, Abel RM. Delayed sternal closure following open-heart operation. Ann Thorac Surg 1981; 32 (3) 273-277
- 6 Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992; 54 (2) 233-239
- 7 Anderson CA, Filsoufi F, Aklog L, Farivar RS, Byrne JG, Adams DH. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. Ann Thorac Surg 2002; 73 (5) 1484-1488
- 8 Shalabi RI, Amin M, Ayed AK, Shuhiber H. Delayed sternal closure is a life saving decision. Ann Thorac Cardiovasc Surg 2002; 8 (4) 220-223
- 9 Hashemzadeh K, Hashemzadeh S. In-hospital outcomes of delayed sternal closure after open cardiac surgery. J Card Surg 2009; 24 (1) 30-33
- 10 Spiliopoulos S, Autschbach R, Koerfer R, Tenderich G. Delayed sternal closure after total artificial heart implantation. J Thorac Cardiovasc Surg 2015; 150 (2) 417-418
- 11 Estrera AL, Porat EE, Miller III CC , et al. Outcomes of delayed sternal closure after complex aortic surgery. Eur J Cardiothorac Surg 2008; 33 (6) 1039-1042
- 12 Fleck T, Kickinger B, Moidl R , et al. Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience. Interact Cardiovasc Thorac Surg 2008; 7 (5) 801-804
- 13 Applebaum RE, Green DC, Sequeira A, McLaughlin JS. Use of a zipper in cardiac surgical operations. Ann Thorac Surg 1987; 43 (2) 227-228
- 14 Rajakaruna C, Rodriguez GM, Rajbanshi BG, Ziganshin BA, Elefteriades JA. Novel technique for delayed sternal closure: soft tissue approximation with substernal bridge. J Thorac Cardiovasc Surg 2014; 148 (5) 2427-2429
- 15 Jones SD, Fullerton DA, Campbell DN , et al. Technique to stent the open sternum after cardiac operations. Ann Thorac Surg 1994; 58 (4) 1186-1187
- 16 Haenen L, Rodrigus IE, Boeckxstaens CJ, Amsel BJ, Moulijn AC. Sternal stent for delayed closure. Ann Thorac Surg 1997; 64 (5) 1519-1520
- 17 Satoh H, Sakai K, Koyama M, Matsuda H. Spool-like stent for the open sternum after cardiac operations. Ann Thorac Surg 1997; 63 (2) 572-574
- 18 Erek E, Kaya M, Tanidir C, Kocyigit OI. Twisted wire stent technique for delayed sternal closure after congenital heart operations. Ann Thorac Surg 2013; 96 (3) 1102-1103
- 19 Kusber H, Chares M, Polonius MJ. Description of a reusable device for the temporary stenting of the open sternum. Thorac Cardiovasc Surg 2002; 50 (2) 117-119
- 20 Santini F, Onorati F, Telesca M, Faggian G, Mazzucco A. Preliminary experience with a new device for delayed sternal closure strategy in cardiac surgery. Int J Artif Organs 2012; 35 (6) 471-476