Related Experiment Videos
[Delayed sternal closure after cardiac surgery]
Y Misawa1, T Hasegawa, K Fukushima
1Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan.
Insights
Delayed sternal closure after cardiac surgery is recommended when pressures rise significantly. This approach, used in 3.5% of patients, improves outcomes for those with unstable hemodynamics, preventing mediastinal infections.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
Context:
- Sternum approximation after cardiac surgery can cause hemodynamic instability, including hypotension and elevated pressures.
- Current practices for sternal closure may not adequately address patients with compromised hemodynamics.
Purpose:
- To propose new criteria for delayed sternal closure based on hemodynamic monitoring.
- To evaluate the safety and efficacy of delayed sternal closure in a cohort of cardiac surgery patients.
Summary:
- A novel criterion for delayed sternal closure is introduced: a sustained increase of >2 mmHg in mean left atrial or central venous pressure during tentative closure.
- This criterion was applied in 3.5% (7/201) of patients, all of whom survived and underwent successful delayed closure.
- While bypass and fibrillation times were longer in the delayed closure group, ischemic times were comparable, and mediastinal cultures were negative, suggesting low infection risk.
Impact:
- Delayed sternal closure is a safe and effective strategy for managing patients with brittle hemodynamics post-cardiac surgery.
- This approach can prevent serious mediastinal infections through careful post-operative management.
- The proposed hemodynamic criteria serve as a reliable predictor for the necessity of delayed sternal closure.
Abstract:
Following cardiac surgery, approximation of sternum will produce systemic hypotension or elevation of left atrial and central venous pressures. A new criteria for delayed sternal closure is proposed. Sternal closure has to be delayed when mean left atrial or central venous pressures increased over 2 mmHg at the tentative closure. In seven cases (3.5%) of consecutive 201 patients was delayed the sternal closure under the above mentioned state, all survived and received the successful closure later. One of them died of congestive heart failure four months after the operation and one died of the rupture of the ascending aortic pseudoaneurysm eleven months after the initial operation. Microbiological examination of the mediastinal and pericardial contents obtained at the final sternal closure were negative in all cases. Comparing the total cardiopulmonary bypass time, ventricular fibrillation time, and myocardial ischemic time between in the secondary closure group and in the primary closure group, the total bypass time and the ventricular fibrillation time of the former were significantly longer than the latter, but the ischemic time revealed no difference. In conclusions, persistent elevation of left atrial or central venous pressures after cardiac surgery at the tentative sternal closure seems the reliable predictor for the delayed closure of the sternum. Careful post-operative management prevents serious mediastinal infection. Delayed sternal closure is preferable procedure for the patient with brittle hemodynamics after open heart surgery.