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Prolonged open sternotomy and delayed sternal closure after cardiac operations
A P Furnary1, J A Magovern, K A Simpson
1Department of Surgery, Allegheny General Hospital, Pittsburgh, PA 15212.
Insights
Delayed sternal closure (DSC) after open sternotomy (OS) in complex cardiac surgery can be successful, with outcomes influenced by patient factors and timing. Bleeding as an indication for OS increased sternal infection risk post-DSC.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Open sternotomy (OS) is sometimes maintained after complex cardiac operations for severely impaired hearts.
- Predictors for the timing, morbidity, and prognosis of delayed sternal closure (DSC) require thorough investigation.
Purpose of the Study:
- To identify predictors of timing, morbidity, and prognosis for delayed sternal closure (DSC) in adult open-heart surgery patients.
Main Methods:
- Retrospective case review of 107 adult open-heart patients with prolonged OS between 1987 and 1991.
- Analysis of indications for OS, timing of DSC, patient survival, and complications such as sternal infection.
Main Results:
- Delayed sternal closure (DSC) was performed in 75 patients, with a 67% survival rate (50/75) discharged after closure.
- Mortality occurred in 57 patients, both before and after DSC.
- DSC success in patients without ventricular assist devices was higher when performed after achieving a negative daily fluid balance (p < 0.002).
- Sternal infection occurred in 5% of DSC patients and was linked to bleeding as the initial OS indication (p < 0.02).
Conclusions:
- Delayed sternal closure (DSC) can be a viable strategy in select complex cardiac surgery patients.
- Achieving a negative fluid balance prior to DSC may improve outcomes in specific patient groups.
- Careful patient selection and monitoring are crucial, especially when bleeding necessitates initial open sternotomy (OS).
Abstract:
Maintenance of an open sternotomy (OS) after a complicated cardiac operation is an adjunct in the treatment of the severely impaired heart. We hypothesized that predictors of the timing, morbidity, and prognosis of delayed sternal closure (DSC) could be determined by intensive case review. Prolonged OS was used in 107 of 6,030 adult open heart patients (1.8%) between 1987 and 1991. Indications for OS were hemodynamic instability (40), myocardial edema (18), intractable bleeding (23), relentless arrhythmias (9), and ventricular assist devices (17). Delayed sternal closure was carried out in 75 of 107 patients at a mean of 3.4 +/- 0.3 days after OS. Fifty of these 75 (67%) survived and were discharged an average of 43 +/- 6 days after closure. Fifty-seven patients died: 32 before DSC at 3.7 +/- 0.8 days after OS and 25 after DSC at 27 +/- 4 days after OS. Baseline cardiac index (1.7 +/- 0.1 L.min-1.m-2) improved an average of 1.0 +/- 0.1 L.min-1.m-2 after OS (p less than or equal to 0.001) and remained stable through DSC (2.5 +/- 0.3 L.min-1.m-2) and late (9 +/- 0.7 days) follow-up (2.8 +/- 0.1 L.min-1.m-2). Delayed sternal closure in patients without ventricular assist devices was significantly more likely to be successful (45/63 versus 9/27; p less than 0.002) when carried out after the onset of a negative daily fluid balance. Sternal infection occurred in 4 of 75 (5%) patients after DSC and was associated with bleeding as an indication for OS (3/15 versus 1/60; p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)