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Pathophysiological Impact of Delayed Sternal Closure on the Respiratory System and Hemodynamics in Pediatric Cardiac

Keisuke Nishida¹, Miyako Kyogoku¹, Muneyuki Takeuchi¹

¹Drs. Nishida, Kyogoku, and Takeuchi are affiliated with the Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.

Respiratory Care

|February 26, 2026

Insights

Delayed sternal closure in pediatric patients increases intrapleural pressure, potentially reducing lung compliance and increasing hemodynamic stress. Optimized respiratory and circulatory support are crucial post-procedure.

Area of Science:

Pediatric Cardiac Surgery
Thoracic Surgery
Intensive Care Medicine

Background:

Delayed sternal closure is common in pediatric cardiac surgery but its respiratory and hemodynamic effects are not well understood.
Previous studies have not assessed intrapleural pressure changes using esophageal pressure measurements after delayed sternal closure.

Purpose of the Study:

To investigate respiratory system and hemodynamic changes following delayed sternal closure in pediatric patients.
To utilize esophageal pressure measurements to estimate intrapleural pressure and assess its impact.

Main Methods:

Retrospective observational study of pediatric patients (<2 years) undergoing delayed sternal closure.
Measurement of respiratory and hemodynamic parameters at three time points: pre-closure, immediately post-closure, and 3 hours post-closure.
Calculation of lung compliance, chest wall compliance, respiratory system compliance, and end-expiratory transpulmonary pressure using esophageal pressure to estimate intrapleural pressure.

Main Results:

Delayed sternal closure significantly increased end-expiratory intrapleural pressure (Ppl).
A trend towards decreased lung compliance was observed 3 hours post-closure.
Heart rate and vasoactive-inotropic score significantly increased after delayed sternal closure.

Conclusions:

Delayed sternal closure elevates intrapleural pressure, potentially decreasing lung compliance and causing hemodynamic stress.
These findings suggest a need for optimized respiratory and circulatory support in pediatric patients undergoing delayed sternal closure.

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Abstract

Background:

Delayed sternal closure is often necessary in pediatric cardiac surgery; however, its impact on the respiratory system and hemodynamics remains unclear. To our knowledge no prior studies have assessed intrapleural pressure (P_pl) changes after delayed sternal closure using esophageal pressure (P_es) measurements. This study aimed to investigate the respiratory system and hemodynamic changes associated with delayed sternal closure in pediatric patients using P_es measurement.

Methods:

This retrospective observational study included subjects <2 years who underwent delayed sternal closure in a pediatric intensive care unit between January and November 2024. Respiratory and hemodynamic parameters were measured at 3 time points: before delayed sternal closure, immediately after delayed sternal closure, and 3 h post delayed sternal closure. P_es was used to estimate P_pl. Lung compliance (C_L), chest wall compliance (C_CW), respiratory system compliance (C_RS), and end-expiratory transpulmonary pressure were calculated. Hemodynamic data included heart rate (HR), vasoactive-inotropic score (VIS), and surrogate indicators of cardiac output.

Results:

Eight subjects were analyzed. End-expiratory P_es significantly increased after delayed sternal closure (before: 6.0 [4.8-7.0] cm H₂O; immediately after: 7.3 [5.8-9.3] cm H₂O; 3 h post delayed sternal closure: 8.1 [6.8-10.1] cm H₂O; P = .044), indicating elevated P_pl. C_L was numerically lower 3 h post delayed sternal closure (before: 0.72 [0.70-0.80] mL/cm H₂O/kg; immediately after: 0.73 [0.65-0.80] mL/cm H₂O/kg; 3 h post delayed sternal closure: 0.62 [0.56-0.74] mL/cm H₂O/kg; P = .09). HR (before: 150 [138-157] beats/min; immediately after: 165 [148-167] beats/min; 3 h post delayed sternal closure: 151 [149-163] beats/min; P = .02) and VIS (before: 12.8 [9.8-14.3]; immediately after: 14.3 [12.1-15.8]; 3 h post delayed sternal closure: 14.8 [12.1-15.8]; P = .003) significantly increased post delayed sternal closure.

Conclusions:

Delayed sternal closure increased P_pl by ∼2 cm H₂O, which may reduce lung compliance without affecting chest wall compliance and contribute to hemodynamic stress. These changes may necessitate optimized respiratory and circulatory support during and after delayed sternal closure.

Keywords:

delayed sternal closure esophageal pressure hemodynamics pediatric cardiac surgery pleural pressure respiratory system

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