Delayed sternal closure for life-threatening complications in cardiac operations: an update

Over a 7-year-period, 25 patients had delayed sternal closure after open heart operations out of 34 patients whose sternum was not closed. The indications were extreme cardiac dilatation and uncontrollable mediastinal hemorrhage. This represented a 1.79% incidence in the overall open heart surgical experience at our unit. Sternal closure was performed at a mean of 2.64 days after the initial operation. Eighteen patients (52.9%) left the hospital alive and well, representing a 72% survival rate among patients undergoing delayed sternal closure. No mediastinal or fatal infection developed and only 1 patient had late superficial wound infection after delayed sternal closure. We conclude that delayed sternal closure is an effective method to treat severe complications after cardiac operations.     

Delayed sternal closure after cardiac surgery]

Following cardiac surgery, approximation of sternum will produce systemic hypotension or elevation of left atrial and central venous pressures. A new criteria for delayed sternal closure is proposed. Sternal closure has to be delayed when mean left atrial or central venous pressures increased over 2 mmHg at the tentative closure. In seven cases (3.5%) of consecutive 201 patients was delayed the sternal closure under the above mentioned state, all survived and received the successful closure later. One of them died of congestive heart failure four months after the operation and one died of the rupture of the ascending aortic pseudoaneurysm eleven months after the initial operation. Microbiological examination of the mediastinal and pericardial contents obtained at the final sternal closure were negative in all cases. Comparing the total cardiopulmonary bypass time, ventricular fibrillation time, and myocardial ischemic time between in the secondary closure group and in the primary closure group, the total bypass time and the ventricular fibrillation time of the former were significantly longer than the latter, but the ischemic time revealed no difference. In conclusions, persistent elevation of left atrial or central venous pressures after cardiac surgery at the tentative sternal closure seems the reliable predictor for the delayed closure of the sternum. Careful post-operative management prevents serious mediastinal infection. Delayed sternal closure is preferable procedure for the patient with brittle hemodynamics after open heart surgery.     

Prolonged open sternotomy and delayed sternal closure after cardiac operations.

Maintenance of an open sternotomy (OS) after a complicated cardiac operation is an adjunct in the treatment of the severely impaired heart. We hypothesized that predictors of the timing, morbidity, and prognosis of delayed sternal closure (DSC) could be determined by intensive case review. Prolonged OS was used in 107 of 6,030 adult open heart patients (1.8%) between 1987 and 1991. Indications for OS were hemodynamic instability (40), myocardial edema (18), intractable bleeding (23), relentless arrhythmias (9), and ventricular assist devices (17). Delayed sternal closure was carried out in 75 of 107 patients at a mean of 3.4 +/- 0.3 days after OS. Fifty of these 75 (67%) survived and were discharged an average of 43 +/- 6 days after closure. Fifty-seven patients died: 32 before DSC at 3.7 +/- 0.8 days after OS and 25 after DSC at 27 +/- 4 days after OS. Baseline cardiac index (1.7 +/- 0.1 L.min-1.m-2) improved an average of 1.0 +/- 0.1 L.min-1.m-2 after OS (p less than or equal to 0.001) and remained stable through DSC (2.5 +/- 0.3 L.min-1.m-2) and late (9 +/- 0.7 days) follow-up (2.8 +/- 0.1 L.min-1.m-2). Delayed sternal closure in patients without ventricular assist devices was significantly more likely to be successful (45/63 versus 9/27; p less than 0.002) when carried out after the onset of a negative daily fluid balance. Sternal infection occurred in 4 of 75 (5%) patients after DSC and was associated with bleeding as an indication for OS (3/15 versus 1/60; p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)     

Delayed Sternal Closure Following Open-Heart Operation

Between June, 1976, and December, 1980, 29 patients underwent delayed sternal closure at the Newark Beth Israel Medical Center. The indications were enlarged heart with tamponade when the mediastinum was closed, poor lung compliance, hemodynamic instability due to intractable arrhythmias or coagulopathy, and presence of a mediastinal assist device.Following an open-heart procedure, the retrosternal space may no longer accommodate the heart and approximation of the sternum will produce hypotension and elevation of right and left end-diastolic pressures. In such instances, only the skin is closed and between one to four days later, the wound is closed in a routine manner.There are several advantages of the procedure: hemodynamic stability; quick access to the heart for massage or evacuation of clots; and possibility of removing an intraaortic balloon in the ascending aorta without leaving a large Dacron tube. Of the 29 patients treated, 19 were long-term survivors and only 1 patient had a minor superficial wound infection.Although it is not recommended that this procedure be utilized routinely or indiscriminately, its judicious use will add flexibility in the management of selected and difficult cases.     

Delayed sternal closure following open-heart surgery in infants and children

Between January, 1982, and December, 1987, 14 patients failed to approximate sternum after open-heart surgery in infants and children. The indications for keeping sternum open were enlarged heart, myocardial edema, severe depression of myocardial contractility and reduced lung compliance due to pulmonary edema. Of the 14 patients, 9 underwent delayed sternal closure between 2nd and 13th postoperative day, and 4 were long-term survivals. All the rest of five patients who were left their sternum open, died of intractable cardiac failure within 16th postoperative day. During the sternum open, three patients suffered from complications-myocardial bleeding in one, and mediastinitis in two. But none of them directly related to the death, and one patient with mediastinitis successfully healed with closed mediastinal irrigation. Although the employment of the delayed sternal closure is rare and limited to the patient with severe heart failure, its judicious use adds advantages in the management of low cardiac output state in infants and children immediately postoperative period.     

Open chest management after cardiac operations: outcome and timing of delayed sternal closure

Objective: Open chest management (OCM) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart. The aim of this study was the evaluation of the incidence, survival and predictors of poor outcome for OCM with delayed sternal closure (DSC), particularly with regard to parameters to determine the time of closure. Methods: Prolonged open chest was used in 212 of 6041 cardiac surgery patients between 2004 and 2009 (3.5%). We wanted to determine indications, mortality, morbidity, predictors of outcome, and parameters for timing of sternal closure. Results: The incidence of open chest (OC) was 3.5%, with 1.4% for isolated coronary artery bypass grafting (CABG), 2.9% for isolated valve, and 7.1% for combined procedures. Indications for OC were: hemodynamic compromise (180), intractable bleeding (14), arrhythmia (12), and cardiac edema or tamponade (six). A total of 153 of the 212 patients with DSC (72%) survived. Fifty-nine patients died: 23 before DSC and 36 after this procedure. Mortality could be related to the indication for OC: With the indication ‘low cardiac output syndrome’ (LCOS), the mortality was 36%, for bleeding it was 25.5%, for arrhythmias 20.5%, and for tamponade on closure it was 18%. After DSC, deep sternal wound infection (DSWI) occurred in 10 patients (5.3%) and superficial infection in 4.8% of patients. There were 18 patients with postoperative stroke (8.5%) and 27 patients with need for dialysis (12.7%). By univariate analysis, ventricular assist device (VAD) insertion, new onset of hemodialysis, re-operation for bleeding, mean length of duration of OC (survivors 3.2 days, non-survivors 6.4 days), and longer duration of high-dose inotropic therapy could be determined as predictors of mortality. Conclusion: With our results, we could demonstrate OCM to be a beneficial, therapeutic option in patients with postoperative LCOS, massive hemorrhage or significant arrhythmias with hemodynamic compromise. However, patients with re-operation for bleeding, need for VAD and particularly a prolonged delay before sternal closure continued to have a poor outcome.     

Delayed sternal closure (DSC) after cardiac surgery: outcome and prognostic markers

Abstract Background: Maintenance of an open sternotomy (OS) after a complicated cardiac operation is an adjunct in the treatment of the severely impaired heart. The purpose of this retrospective study was to evaluate the incidence, survival, and predictors of poor outcome for open chest management (OCM) with delayed sternal closure (DSC) at our department. Methods: Prolonged open chest (OC) was used in 179 of 5122 cardiac surgery patients between 2004 and 2008 (3.5%). We wanted to determine indications, mortality, postoperative complications, and predictors of outcome. Results: The incidence of OS was 3.5%, with 1.3% for isolated CABG, 2.4% for isolated valve, and 6.4% for combined procedures. Indications for OS were: hemodynamic compromise (110), intractable bleeding (19), arrhythmia (14), and cardiac edema or tamponade (36). 127 of the 179 patients with DSC (71%) survived. 52 patients died: 20 before DSC and 32 after this procedure. Mortality could be related to the indication for OS: With the indication “low cardiac output syndrome” (LCOS) the mortality was 34.5%, for bleeding it was 26.3%, for arrhythmias, 21.4%, and for tamponade on closure it was 16.7%. After DSC, deep sternal wound infection occurred in nine patients (5%), superficial infection in 4.7% of patients. There were 16 patients with postoperative stroke (8.9%) and 24 patients with need for dialysis (13.4%). Predictors of mortality by univariate analysis were VAD insertion, new onset of hemodialysis, reoperation for bleeding, mean length of duration of OS (survivors 3.4 days, nonsurvivors 6.5 days), and longer duration of high‐dose inotropic therapy. Conclusion: This study shows that OCM with DSC is a beneficial, therapeutic option in patients with postoperative LCOS, significant hemorrhage or intractable arrhythmias. However, patients with reoperation for bleeding, need for VAD, and particularly a prolonged delay before sternal closure continued to have a poor outcome. (J Card Surg 2011;26:22‐27)     

Norwood Operation: Immediate vs Delayed Sternal Closure

BackgroundThe Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications.MethodsThis retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure).ResultsThe incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%).ConclusionsFor important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.     

Sternotomy wound closure with polyester tapes

We developed the special polyester tape with Tetron coating for sternal closure. Fifty consecutive open heart cases had the sternum closed with the tapes in the past six months at Nippon Medical School Hospital. There was no sternal infection or mediastinitis postoperatively. The tape closure method was more effective in approximation of sternum than the ordinary wire closure, especially in the case with fragile sternum. Although a long term follow-up is necessary, the result of sternal closure with the polyester tape has been satisfactory.     

Delayed sternal closure after cardiac surgery

Fifty-seven patients undergoing various cardiac operations were managed with delayed sternal closure because of ongoing mediastinal hemorrhage or extreme cardiac dilatation. This strategy facilitated rapid access to the mediastinum for evacuation of clot when the risk of tamponade from hemorrhage was deemed great. When sternal closure over a dilated and edematous heart caused hemodynamically significant cardiac compression, wound closure without sternal reapproximation facilitated hemodynamic stability. Postoperative correction of hemodynamic and hemostatic functions allowed delayed sternal closure to be done a mean of 2.8 days later. Thirty-eight patients survived to leave the hospital. Recognized complications of delayed sternal closure included superficial wound infection (3 patients), sternal osteomyelitis (1 patient), and fatal mediastinal infection (1 patient). Delayed sternal closure may be beneficial in selected patients. Morbidity and mortality related to this technique have proved acceptable in this high-risk group.     

Clinical analysis of the patients with delayed sternal closure following open heart surgery

Thirteen patients with successful or unsuccessful delayed sternal closure (DSC) after open heart surgery were reviewed. The indications of DSC were cardiac dilatation in 12 patients and intractable bleeding in one. Patients were divided into two groups as follows: Group A of 7 patients with mediastinum being sealed by prosthetic material, and Group B of 6 patients with primary skin closure by mobilized skin-flap. Postoperative complications and prognosis were compared between these two groups. There were 6 long term survivors. In group A, there were 4 deaths, 2 from low output syndrome (LOS) and 2 from sepsis due to mediastinitis. In group B, 2 died of LOS and 1 died of multiple organ failure, while no patients developed mediastinitis. In patients with unsuccessful DSC, mainly due to poor hemodynamics, there found no tendencies of decrease in CVP and LAP levels and no reduction in the amount of catecholamine dosage prior to attempted DSC. In conclusion, 1) mediastinal isolation with primary skin closure seemed more effective for preventing mediastinitis than coverage with prosthetic materials, 2) DSC was possible when there were hemodynamic improvements with decrease in CVP and LAP levels, and reduction in catecholamine dosage, and 3) plastic surgical technique was useful for primary skin closure.     

胸骨裂开的原因及固定方法

胸骨裂开的原因主要是纵隔感染,恶性肥胖病人（多数合并糖尿病）易发。而胸骨固定的方法多样,如传统6钢丝胸骨固定、连锁“8”字缝合固定、Robicsek方法、改良Robicsek法、钢板固定等,各有不同的适应证,通过术前正确的评估胸骨裂开的高危因素,选择合理的固定方法,将有助于减少胸骨裂开的可能性。     

Staged chest closure in pediatric cardiac surgery preventing typical and atypical cardiac tamponade.

Chest closure after cardiac surgery occasionally results in cardiac compression leading to circulatory failure. In shunt-dependent circulation, the arterial oxygen saturation may decrease significantly due to the increase in pulmonary vascular resistance caused by chest closure. Temporary patch implantation with delayed sternal closure facilitates circulatory and/or pulmonary stabilization (temporary chest wall patch plasty, TCWPP). Between July 1986 and June 1991, 42 patients underwent staged chest closure (TCWPP) after open heart surgery for congenital lesions (4.9% of 854 patients). TCWPP was performed when either primary hemodynamic deterioration or an increase in cyanosis (palliative procedures only) followed by hemodynamic deterioration occurred during attempted or shortly after sternal closure. Overall mortality was 40.4% (17/42). It was 32.3% (11/34) when the patch was inserted primarily at the end of the operation. If the patch was inserted emergently 4-24 h postoperatively, mortality was 75% (6/8). Definite chest closure was performed from 4 h to 6 days (mean 72 h) postoperatively. In 2 patients closure had to be performed emergently (single ventricles); 7 patients died before chest closure. One mediastinal microbiology examination was positive. Deep sternal infection necessitating operative revision occurred in one other patient. In conclusion, TCWPP may considerably lower mortality of the illest patients after surgery for complex congenital heart disease. A timely decision as to the performance of staged chest closure is mandatory. This procedure rarely causes infection. We now apply this technique liberally, by cardio-mediastinal size judgement in over 30% of our TCWPP candidates even without a prior trial of primary closure.     

Mediastinal infection following open-heart surgery. Treatment with retrosternal irrigation

A consecutive series of 1083 patients undergoing open-heart surgery was prospectively observed for infectious complications. Postoperative mediastinitis developed in 15 cases (1.4%). Surgical management of the mediastinal complication consisted of careful debridement of the sternal wound and the anterior mediastinum, followed by continuous retrosternal irrigation with an antiseptic or antibiotic solution after sternal refixation. The mean duration of mediastinal irrigation was 12.7 days. This treatment was successful in 13 of the 15 patients. In 2 of the 13, however, secondary refixation became necessary to stabilize the fragmented sternum. Repeated refixation with mediastinal irrigation was effective in one of these patients. The other underwent removal of the fragmented sternum followed by muscle plasty, but died unexpectedly of aortic dissection when signs of infection were subsiding. Two patients (13%) treated with closed chest irrigation died of recalcitrant mediastinal infection.     

延迟关胸在儿童心脏移植中的应用

目的探讨延迟关胸技术在儿童心脏移植中的应用价值。 方法回顾性分析华中科技大学同济医学院附属协和医院2018年1月1日至2021年8月31日73例儿童心脏移植受者临床资料,根据术后一期胸骨闭合情况分为延迟关胸组(10例)和非延迟关胸组(63例),分析延迟关胸对于受者心功能恢复、手术切口感染、肺部感染、术后30 d和住院期间死亡情况的影响。 结果延迟关胸组原发病以复杂先天性心脏病心力衰竭为主,非延迟关胸组以心肌病心力衰竭为主。延迟关胸组延迟关胸时间中位数4 d,采用一次或分次关胸技术均成功关胸。延迟关胸组平均年龄(6.4±5.3)岁,平均体质量(16.3±11.4)Kg,均小于非延迟关胸组[(9.7±4.7)岁和(29.5±15.6)Kg];供受者体质量比为(3.1±1.4),高于非延迟关胸组[(1.9±0.7)],差异均有统计学意义(t＝2.0、3.2和-4.5,P均<0.05)。延迟关胸组术前和术后使用VA-ECMO辅助、术后肾脏替代治疗的受者比例以及发生肺部感染和住院期间死亡的受者比例均高于非延迟关胸组,差异均有统计学意义(P均<0.05)。延迟关胸组受者术后2周右室面积变化分数为(37.0±5.8)%,低于非延迟关胸组[(43.1±7.8)%],差异有统计学意义(t＝2.4,P<0.05)。2组受者性别、术前血清总胆红素和肌酐、术后2周左室射血分数、手术切口感染及术后30 d内死亡发生率差异均无统计学意义(P均>0.05)。 结论延迟关胸是儿童心脏移植供受者体质量不匹配时一种安全且有效的治疗策略。     

A prospective randomized study of sternal closure: comparison of Mersilene tape versus standard wire closure.

BACKGROUND: To compare in a prospective randomized study Mersilene tape and standard metal wire for complications and pain upon sternal wound closure. METHODS: Sixty-four patients scheduled for cardiac surgery were prospectively randomized to undergo sternal closure using either Mersilene tape (n=30) or standard metal wire (n=34). The intensity of postoperative pain from the chest wound was assessed using a visual analogue scale (VAS) on the second and seventh postoperative days and one month after surgery. The examinations with chest X-ray and computed tomography (CT) one month after surgery were performed to evaluate the chest wound and sternum. Follow-up data on sternal and wound healing was assessed for up to one year. RESULTS: No deaths, sternal dehiscence or infection occurred in either group. No wound complications were observed in either group during the year following surgery. A review of data revealed that there was no difference in the intensity of postoperative pain according to the VAS between the two groups. Chest CT demonstrated that no patients in either group had cuts in the sternum. CONCLUSION: This prospective randomized study showed Mersilene tape sternal closure not to be more closely associated with increased complications or patient discomfort due to sternal wound than the standard wire closure.     

Reconstruction of chronic aseptic sternal pseudoarthrosis after median sternotomy: initial experience with the Ley prosthesis

It has previously been reported that the Ley prosthesis, a 0.5-mm-thick titanium alloy plate designed for reconstruction and stabilization of the unstable sternotomy, leads to shorter hospital stay and reduces the need for further surgical procedures in patients with postoperative mediastinitis after open heart surgery. We report our initial experience with the Ley prosthesis in patients with chronic aseptic sternotomy dehiscence. The study included 6 male patients (age 42-80 years) with opiate-derivate-dependent intractable pain and significantly reduced quality of life caused by noninfected sternal pseudoarthrosis and unstable sternotomy with large sternal bone tissue deficit. Four of the patients had undergone various surgical fixation procedures 8 days to 12 months after the primary operation. The patients were treated with reconstruction and stabilization of the sternum with the Ley prosthesis 10 to 40 months after the primary operation. In 1 patient bone transplantation was used. No immediate peri- or postoperative complications were observed, and all patients were discharged 4 to 11 days after surgery. One patient who received a bone transplant developed wound infection, and the prosthesis was removed 5 weeks after implantation. At 6-month follow-up all sternotomies were found stable, and patients reported that pain had decreased and quality of life was significantly improved. Our results demonstrate that the Ley prosthesis can be safely and efficiently used for the reconstruction and stabilization of the sternum in patients with intractable pain caused by noninfected postoperative sternal dehiscence and large sternal bone tissue deficit.     

Delayed sternal closure after open heart surgery in neonates and early infants

Between November 1992 and February 1996, 84 patients (less than 3 months of age) underwent open heart surgery. Among 76 patients except 8 who required mechanical circulatory support, the sternum was left open. The indication of open sternotomy was hypoplastic left heart syndrome in 14 patients and unstable hemodynamics in 4 patients. Three patients died before delayed sternal closure. Delayed sternal closure was carried out in 15 patients with a mean of 4.7 days postoperatively. By the time of sternal closure, blood pressure, left atrial pressure and respiratory parameters improved and inotropics were reduced with the minus fluid balance. One patient died of sepsis 4 days after delayed sternal closure. Delayed sternal closure was effective modality to neonates or early infants after complex open heart surgery.     

Use of a zipper in cardiac surgical operations

A simplified technique to gain repeated access to the median sternotomy incision is presented. The technique involves the use of a sterile polyester zipper attached to the skin edge. The sternum remains open. Unzipping the zipper allows for repeated relief of cardiac tamponade and viewing of cardiac action. Other advantages include prevention of cardiac compression or kinking of assist device cannulas from sternal closure, ease in changing of dressings, and quick removal of ventricular assist devices without reopening the sternum.     

Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy

BACKGROUND: Vacuum-assisted closure therapy is a novel treatment employed to aid wound healing in different areas of the body and recently also in sternotomy wounds. Aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the rate of possible rewiring. METHODS: The records of 40 consecutive patients with deep sternal wound infection were reviewed. Sternal bone sparing was achieved by using layers of paraffin gauze (Jelonet; Smith and Nephew Medical, Hull, UK) at the bottom of the wound in order to cover and protect visible parts of the right ventricle, lung tissue, and grafts from the sternal edges. Two separate layers of polyurethane foam (KCI, Copenhagen, Denmark) were placed so as to fit between the sternal edges and subcutaneously. A continuous negative pressure of 125 mm Hg was applied and subsequent revision was made exclusively in nongranulation areas. RESULTS: There were no deaths during the 90 days of follow-up. Three late deaths unrelated to the infection and three subcutaneous fistulas occurred during the total follow-up period (3 to 41 months). The median duration of the vacuum-assisted closure therapy was 10 days (range, 3 to 34). The series represents a total of 474 days with the vacuum-assisted closure device without serious adverse events. CONCLUSIONS: In our opinion this modified vacuum-assisted closure therapy is a safe and reproducible option to bridge patients with postoperative deep sternal wound infection to complete healing. Reconstruction of the sternum was achieved in all patients without the use of muscle or omental flap surgery.