Thorac cardiovasc Surg
DOI: 10.1055/s-0037-1599132
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Elective Primary or Secondary Delayed Sternal Closure Improves Outcome in Severely Compromised Patients

Antonio M. Calafiore1, Azmat A. Sheikh1, Juan J. Alfonso1, Tarek Tantawi1, Belgeit Maklouf1, Ahmed Shawki1, Ahmed Allam1, 2, Mohammed O. Awadi1, 3, Ahmed A. Osman1, 4, Aly M. Habib1, 4, Michele Di Mauro1, 5
  • 1Departments of Cardiac Surgery and Critical Care, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
  • 2Department of Cardiothoracic Surgery, Ain Shams Univeristy, Ain Shams, Egypt
  • 3Department of Cardiothoracic Surgery, Benha University, Benha, Egypt
  • 4Department of Critical Care, Cairo University, Cairo, Egypt
  • 5Department of Cardiology, L'Aquila University, L'Aquila, Palermo, Italy
Further Information

Publication History

20 November 2016

10 January 2017

Publication Date:
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.