Delayed Sternal Closure After Pediatric Heart Transplant

Delayed sternal closure (DSC) is frequently used after pediatric heart transplantation when immediate closure may compromise hemodynamics or respiratory mechanics. However, limited data describe the timing, safety, infection risk, and physiologic effects of DSC in this population. We aimed to characterize the use of DSC after pediatric heart transplantation, including time to closure, infectious complications, and changes in hemodynamic and respiratory parameters using both electronic health record data and high-fidelity continuous monitoring. We conducted a retrospective descriptive study at Texas Children's Hospital in Houston, Texas. Patients who underwent DSC after pediatric heart transplantation between January 1, 2013, and March 1, 2023, were identified through the Society of Thoracic Surgeons database. Continuous vital-sign data were obtained from the Sickbay high-fidelity monitoring platform and supplemented with data from the electronic health record. Vasoactive medication use, administered fluid volume, and urine output were collected from the electronic health record. Low-frequency peri-closure data were compared before and after DSC, and multilevel mixed-effects models were used to evaluate changes in continuously recorded hemodynamic variables. Thirty-two patient encounters were included. The median time to sternal closure was 2.79 days after transplantation. Analysis of low-frequency data showed statistically significant increases in respiratory rate, peak inspiratory pressure, and fraction of inspired oxygen after DSC; however, the magnitude of these changes was not clinically significant. Multilevel mixed-effects analysis of high-fidelity continuous data demonstrated no statistically significant changes in hemodynamic parameters after DSC. No patient required sternal reopening following closure. Two patients developed infections. Delayed sternal closure was well tolerated after pediatric heart transplantation and was typically performed within 2 to 3 days. Closure was not associated with clinically meaningful hemodynamic deterioration, the infection rate was low, and no patient required sternal reopening. These findings support the safety of DSC in carefully selected pediatric heart transplant recipients.