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Repeat median sternotomy in pediatrics: experience in 164 consecutive cases
Insights
Repeat median sternotomy in children is feasible with careful technique, showing comparable bleeding risks to initial procedures. This approach offers a valuable option for pediatric cardiac surgery reoperations.
Area of Science:
- Pediatric Cardiac Surgery
- Thoracic Surgery
- Cardiovascular Surgery
Background:
- Repeat median sternotomy is often necessary for reoperations in pediatric cardiac surgery.
- Challenges include increased risk of adhesions and potential injury during sternal reentry.
Purpose of the Study:
- To evaluate the safety and efficacy of a specific technique for repeat median sternotomy in children.
- To compare outcomes between initial and repeat sternotomy procedures.
Main Methods:
- A cohort of 138 children underwent 164 repeat median sternotomies.
- The technique involved careful sternal opening, blunt dissection, avoidance of electrocautery for adhesions, and judicious use of blood products.
- Variables analyzed included time to bypass, bleeding, and operative injuries.
Main Results:
- Repeat sternotomy took approximately one hour longer than initial procedures (174 vs. 96 minutes).
- Operative transfusions and postoperative bleeding were not significantly different between initial and repeat sternotomies.
- Eight injuries (5%) occurred during reoperation, with no deaths directly related to the technique.
Conclusions:
- The described technique for repeat median sternotomy in children is safe and effective.
- It provides a valuable alternative for managing pediatric cardiac surgery reoperations with acceptable complication rates.
Abstract:
One hundred thirty-eight children underwent 164 operations through repeat median sternotomy. Ages ranged from 4 months to 21 years (mean, 8.6 +/- 5.0 years). The technique consisted of opening the sternum with chisel and mallet, avoidance of sudden separation of sternal edges and blunt dissection, elimination of the electrocautery during lysis of adhesions, and judicious use of fresh blood and components. Several variables were analyzed comparing the initial and repeat procedures on each patient. Time from incision to bypass was an hour longer with the repeat procedure (174 +/- 45 minutes versus 96 +/- 37 minutes). Operative transfusions and postoperative bleeding (first 48 hours) were not significantly different between the two procedures. Cyanosis, however, significantly increased bleeding in both groups. There were eight injuries (5%) at reoperation. During sternal reentry in 2 patients, a tear occurred in a valved conduit coursing underneath the sternum. A right ventricular tear occurred in 1 patient while the sternal edges were being separated. Ventricular fibrillation was noted in 2 patients during lysis of adhesions with the electrocautery used early in the series. Intimal disruption occurred in two valved conduits during intraoperative manipulations. An aortic tear occurred and was repaired without cardiopulmonary bypass. There were 13 (8%) hospital deaths, all unrelated to the technique. We believe that the current approach can be a valuable alternative for surgeons dealing with repeat median sternotomy in children.