Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery
Mohamed F Elsisy1, Joseph A Dearani1, Juan A Crestanello1
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Insights
Primary delayed sternal closure (DSC) in pediatric cardiac surgery leads to better outcomes than secondary DSC (reopening the sternum). Anticipated DSC improves survival and reduces hospital stay compared to sternal reopening.
Area of Science:
- Pediatric Cardiac Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Delayed sternal closure (DSC) is a strategy for managing hemodynamic instability and coagulopathy in complex congenital heart surgery.
- The study compares outcomes of DSC versus perioperative sternal reopening.
Purpose of the Study:
- To evaluate the hypothesis that delayed sternal closure (DSC) yields better outcomes than perioperative sternal reopening.
- To compare outcomes between primary DSC (PDSC) and secondary DSC (SDSC) in pediatric cardiac surgery patients.
Main Methods:
- A retrospective review of pediatric patients (<18 years) undergoing cardiac surgery between 2007-2017.
- Patients were categorized into primary DSC (PDSC) within 2 days, PDSC >2 days, and secondary DSC (SDSC).
- Perioperative characteristics and outcomes were analyzed across the three groups.
Main Results:
- Primary DSC (PDSC) demonstrated significantly better survival rates than secondary DSC (SDSC).
- Secondary DSC (SDSC) was associated with higher operative mortality (17.8%) and longer hospital stays (57 days) compared to PDSC.
- Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group.
Conclusions:
- Primary delayed sternal closure (PDSC) is associated with superior outcomes compared to secondary DSC (SDSC).
- While sternal reopening can be life-saving, anticipated PDSC offers improved results in pediatric cardiac surgery patients.
Background:
Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening.
Methods:
We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed.
Results:
Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC.
Conclusions:
PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.
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