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Open chest and delayed sternal closure after cardiac surgery
J T Christenson1, J Maurice, F Simonet
1Cardiovascular Unit, Hôpital de la Tour, Geneva, Switzerland.
Insights
Open chest with delayed sternal closure is a beneficial treatment for severe heart impairment after cardiac surgery. This method shows encouraging long-term results with manageable sternal morbidity.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Open chest (OC) with delayed sternal closure (DSC) is a recognized technique for managing severe cardiac dysfunction post-surgery.
- Its application is particularly noted in cases of hemodynamic compromise, intractable bleeding, or persistent arrhythmias.
Purpose of the Study:
- To evaluate the efficacy and safety of open chest with delayed sternal closure in adult cardiac surgery.
- To assess the impact of DSC on patient survival, sternal wound complications, and long-term outcomes.
Main Methods:
- A retrospective analysis of 142 patients undergoing prolonged open chest procedures (4.2% of 3373 adult cardiac operations) between 1987 and 1993.
- Indications included hemodynamic compromise (121), bleeding (9), and arrhythmias (12). DSC was performed in 123 patients.
- Comparison of outcomes based on indications for OC and use of intraaortic balloon pump support.
Main Results:
- Of 123 patients undergoing DSC, 78.9% survived and were discharged.
- Mortality rates varied by indication: low cardiac output (38.6%), bleeding (33.3%), arrhythmias (27.3%), and hemodynamic collapse (0%).
- DSC without intraaortic balloon pump support showed significantly lower mortality (16.0% vs. 46.3%). Sternal morbidity rates were comparable to primary closure.
Conclusions:
- Open chest with delayed sternal closure is a valuable adjunct for managing postoperative cardiac dysfunction, hemorrhage, and arrhythmias.
- The procedure can be performed without increasing sternal morbidity.
- Long-term follow-up indicates encouraging survival rates and functional improvement (NYHA class).
Objectives:
Open chest (OC) and subsequent delayed sternal closure (DSC) has been described as a useful method in the treatment of the severely impaired heart after cardiac surgery.
Methods:
Prolonged open chest was used in 142 to 3373 adult cardiac operations (4.2%) between January 1987 and December 1993. The indications were: hemodynamic compromise (121), intractable bleeding (9) and arrhythmias (12). Delayed sternal closure was carried out in 123 of 142 patients at a mean of 2.0 +/- 1.4 days (range 0.5-8 days). Open chest and DSC were used proportionally more frequently after combined cardiac surgery (28/293, 9.6%) than after coronary artery bypass grafting (CABG) alone (108/2891, 3.7%) or valve operation (6/230, 2.6%).
Results:
Ninety-seven of the 123 who had DSC (78.9%) survived and were discharged an average of 8.6 +/- 4.2 days after closure. Fourty-five patients died: 19 before DSC and 26 after this method. Mortality was related to indications for OC: when the indication was low cardiac output the mortality was 38.6%, for hemodynamic collapse on closure 0%, diffuse bleeding 33.3% and arrhythmias 27.3%. Delayed sternal closure in patients without intraaortic balloon pump support was more likely to be successful (mortality rate 4/25, 16.0% versus 35/76, 46.3%, P < 0.01). Superficial sternal wound infection occurred in 2 of 123 (1.6%) patients after DSC, mediastinitis in 1 (0.8%) and sternal dehiscence in 3 (2.4%) patients, which does not differ from a control population that had primary sternal closure. The follow-up of 97 survivors at an average of 28 +/- 4 months revealed an improvement of NYHA class by 1.4 +/- 0.4. There were 16 deaths (13 cardia-related) during the follow-up period and 3 redo CABG. One case of sternal osteomyelitis occurred without any other late sternal morbidity.
Conclusions:
This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias. It can be performed without increased sternal morbidity. Long-term results are also encouraging.