Related Experiment Videos
Selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass
J A Johnson1, A E Gundersen, I D Stickney
1Department of Thoracic and Cardiovascular Surgery, Gundersen/Lutheran Medical Center, La Crosse, Wisconsin.
Insights
Selective sternal closure after coronary artery bypass grafting (CABG) hemorrhage exploration is effective. Immediate closure is suitable for controlled bleeding, while delayed closure manages refractory hemorrhage, reducing complications.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
Background:
- Hemorrhage requiring exploration is a complication after coronary artery bypass grafting (CABG).
- Sternal closure strategies influence patient outcomes post-CABG hemorrhage exploration.
Purpose of the Study:
- To evaluate the outcomes of immediate versus delayed sternal closure in patients undergoing exploration for hemorrhage after CABG.
- To determine the optimal approach for sternal closure based on bleeding control and coagulopathy.
Main Methods:
- Retrospective review of 788 patients undergoing CABG, identifying 36 who required exploration for hemorrhage.
- Categorization of patients based on sternal closure strategy: immediate closure versus initial delayed sternal closure.
- Analysis of outcomes including reexploration, mortality, and sternal wound infections.
Main Results:
- Twenty-three patients managed with immediate sternal closure had no deaths or infections; 5 required reexploration with delayed closure.
- Thirteen patients initially treated with delayed sternal closure due to coagulopathy had one death and no infections.
- Selective sternal closure approach demonstrated favorable outcomes in managing post-CABG hemorrhage.
Conclusions:
- A selective approach to sternal closure after CABG hemorrhage exploration is supported.
- Immediate sternal closure is appropriate when bleeding is surgically controlled.
- Delayed sternal closure should be considered for refractory hemorrhage due to coagulopathy to prevent complications.
Abstract:
Thirty-six (4.6%) patients required exploration for hemorrhage after 788 coronary artery bypass grafting procedures. Twenty-three (64%) patients with a specific site of bleeding that was surgically controlled or with improving coagulopathy were managed by immediate sternal closure. Continued hemorrhage or tamponade necessitated reexploration in 5 of these patients. All 5 patients were then treated by open sternotomy and delayed sternal closure. There were no deaths or sternal wound infections in this subgroup. Thirteen (36%) patients explored for hemorrhage were initially treated by open sternotomy and delayed sternal closure because of ongoing coagulopathy with refractory bleeding. Twelve patients recovered without further complication. One patient died 30 days after delayed sternal closure. There were no sternal wound infections. This experience supports a selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass grafting. Immediate closure is recommended if a specific site of bleeding can be located and corrected. However, in the presence of refractory hemorrhage due to coagulopathy, delayed sternal closure should be considered to avoid the subsequent morbidity of continued bleeding, including cardiac tamponade, multiple reexplorations with sternal trauma, and retained mediastinal hematoma.