Open chest management after cardiac operations: outcome and timing of delayed sternal closure

Open chest management (OCM) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart. The aim of this study was the evaluation of the incidence, survival and predictors of poor outcome for OCM with delayed sternal closure (DSC), particularly with regard to parameters to determine the time of closure.

Prolonged open chest was used in 212 of 6041 cardiac surgery patients between 2004 and 2009 (3.5%). We wanted to determine indications, mortality, morbidity, predictors of outcome, and parameters for timing of sternal closure.

The incidence of open chest (OC) was 3.5%, with 1.4% for isolated coronary artery bypass grafting (CABG), 2.9% for isolated valve, and 7.1% for combined procedures. Indications for OC were: hemodynamic compromise (180), intractable bleeding (14), arrhythmia (12), and cardiac edema or tamponade (six). A total of 153 of the 212 patients with DSC (72%) survived. Fifty-nine patients died: 23 before DSC and 36 after this procedure. Mortality could be related to the indication for OC: With the indication 'low cardiac output syndrome' (LCOS), the mortality was 36%, for bleeding it was 25.5%, for arrhythmias 20.5%, and for tamponade on closure it was 18%. After DSC, deep sternal wound infection (DSWI) occurred in 10 patients (5.3%) and superficial infection in 4.8% of patients. There were 18 patients with postoperative stroke (8.5%) and 27 patients with need for dialysis (12.7%). By univariate analysis, ventricular assist device (VAD) insertion, new onset of hemodialysis, re-operation for bleeding, mean length of duration of OC (survivors 3.2 days, non-survivors 6.4 days), and longer duration of high-dose inotropic therapy could be determined as predictors of mortality.

With our results, we could demonstrate OCM to be a beneficial, therapeutic option in patients with postoperative LCOS, massive hemorrhage or significant arrhythmias with hemodynamic compromise. However, patients with re-operation for bleeding, need for VAD and particularly a prolonged delay before sternal closure continued to have a poor outcome.