Related Experiment Videos
Staged chest closure in pediatric cardiac surgery preventing typical and atypical cardiac tamponade
1Division of Thoracic Surgery, Children's Hospital, Hannover Medical School, FRG.
Insights
Temporary chest wall patch plasty (TCWPP) stabilizes patients after complex congenital heart surgery. This staged closure reduces mortality in critically ill infants, with infection being rare.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Chest closure after cardiac surgery can cause circulatory failure, especially in patients with shunt-dependent circulation.
- Increased pulmonary vascular resistance post-sternotomy can lead to decreased arterial oxygen saturation.
Purpose of the Study:
- To evaluate the efficacy of temporary chest wall patch plasty (TCWPP) in stabilizing patients with circulatory or pulmonary compromise after congenital heart surgery.
- To assess the impact of TCWPP on mortality rates in high-risk pediatric cardiac surgery patients.
Main Methods:
- Retrospective analysis of 42 patients undergoing TCWPP between July 1986 and June 1991 for congenital heart lesions.
- TCWPP was performed when hemodynamic deterioration or cyanosis occurred during or after attempted sternal closure.
- Comparison of mortality based on the timing of patch insertion (primary vs. emergent).
Main Results:
- Overall mortality was 40.4% (17/42).
- Mortality was lower when TCWPP was performed primarily at the end of surgery (32.3%) compared to emergent insertion (75%).
- Infection rates were low, with one positive mediastinal culture and one deep sternal infection requiring revision.
Conclusions:
- TCWPP can significantly lower mortality in critically ill patients undergoing surgery for complex congenital heart disease.
- Timely decision-making for staged chest closure is crucial for patient outcomes.
- The procedure is associated with a low risk of infection and is now applied more liberally based on clinical judgment.
Abstract:
Chest closure after cardiac surgery occasionally results in cardiac compression leading to circulatory failure. In shunt-dependent circulation, the arterial oxygen saturation may decrease significantly due to the increase in pulmonary vascular resistance caused by chest closure. Temporary patch implantation with delayed sternal closure facilitates circulatory and/or pulmonary stabilization (temporary chest wall patch plasty, TCWPP). Between July 1986 and June 1991, 42 patients underwent staged chest closure (TCWPP) after open heart surgery for congenital lesions (4.9% of 854 patients). TCWPP was performed when either primary hemodynamic deterioration or an increase in cyanosis (palliative procedures only) followed by hemodynamic deterioration occurred during attempted or shortly after sternal closure. Overall mortality was 40.4% (17/42). It was 32.3% (11/34) when the patch was inserted primarily at the end of the operation. If the patch was inserted emergently 4-24 h postoperatively, mortality was 75% (6/8). Definite chest closure was performed from 4 h to 6 days (mean 72 h) postoperatively. In 2 patients closure had to be performed emergently (single ventricles); 7 patients died before chest closure. One mediastinal microbiology examination was positive. Deep sternal infection necessitating operative revision occurred in one other patient. In conclusion, TCWPP may considerably lower mortality of the illest patients after surgery for complex congenital heart disease. A timely decision as to the performance of staged chest closure is mandatory. This procedure rarely causes infection. We now apply this technique liberally, by cardio-mediastinal size judgement in over 30% of our TCWPP candidates even without a prior trial of primary closure.