Primary Sternal Closure Research Articles

Thyroid function and ioduria in infants after cardiac surgery: Comparison of patients with primary and delayed sternal closure

Thyroid hormone alterations after cardiac surgery may be aggravated by the use of iodine antiseptics. We evaluated thyroid function and ioduria in infants with delayed sternal closure (DSC) who are exposed to povidone-iodine for sternal wound protection and compared them with findings in infants after primary sternal closure. Prospective clinical study. Pediatric cardiac intensive care unit. Ninety-three infants after cardiac surgery using cardiopulmonary bypass, 60 of them with primary sternal closure and 33 of them with delayed sternal closure. Thyroid hormones were studied in patients with primary sternal closure immediately after surgery, 5 days and 19 days after surgery, in patients with DSC immediately after surgery, immediately after sternal closure, and 2 wks after sternal closure. Ioduria was evaluated on the first, third, and fifth postoperative days after cardiac surgery with primary sternal closure and immediately after DSC. In both groups of patients, low total triiodothyronine, total thyroxine, thyroxine-binding globulin levels, high reverse triiodothyronine levels, and normal free triiodothyronine, free thyroxine, and thyroid-stimulating hormone levels were recorded immediately after surgery. Concentrations of total triiodothyronine and thyroid-stimulating hormone were lower in the patients with DSC. Five days after primary sternal closure and 2 wks after DSC, all thyroid hormone levels were normal for age. Ioduria after DSC was higher than ioduria after primary sternal closure. Patients with DSC compared with patients with primary sternal closure display more profound thyroid suppression in the immediate postoperative period. The use of povidone-iodine adhesive drapes with single povidone-iodine mediastinal irrigation in patients with DSC is associated with significant iodine absorption but no significant thyroid dysfunction.

Mediastinitis after pediatric cardiac surgery: a 15-year experience at a single institution

Background The spectrum of sternal wound infections after cardiac surgery ranges from superficial infections to a deep sternal infection known as mediastinitis. Mediastinitis is a rare but clinically relevant source of postoperative morbidity and mortality in adult and pediatric patients after cardiac surgery. Methods We retrospectively identified all patients diagnosed with mediastinitis after cardiac surgery from January 1987 to December 2002 (17 patients/7,616 surgeries = 0.2%). Demographic data, cardiac diagnosis, cardiac surgery, hospital length of stay, associated medical diagnosis, and surgical treatment for mediastinitis were collected. Results Fifteen pediatric patients (age < 18 years) were diagnosed with mediastinitis (mean age at diagnosis 37.5 months, range 21 days to 17 years. The median postoperative day of diagnosis was 14 days (6 to 50 days). The most common organism was Staphylococcus species (n = 9). Six patients had an associated bacteremia. The median hospital length of stay for all patients was 42.5 days (range 16 to 163 days). The hospital mortality was 1 of 15 (6%). Each patient was treated with intravenous antibiotics; sternal debridement; and rectus abdominus flap reconstruction (n = 7), pectoralis muscle flap reconstruction (n = 3), omentum reconstruction (n = 1), or primary sternal closure (n = 4). Three patients have undergone redo-sternotomy with orthotopic heart transplantation, bidirectional cavopulmonary anastomosis, and replacement of a right ventricle to pulmonary artery homograft. Conclusions Timely diagnosis, aggressive sternal debridement, and liberal use of rotational muscle flaps can potentially minimize the morbidity and mortality in pediatric postoperative cardiac patients. Subsequent redo-sternotomy has not been problematic.

Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability

Background. The purpose of this retrospective study was to evaluate the current incidence, survival, and predictors of mortality for open chest management at our center. Methods. Our database was analyzed to identify adult postcardiotomy patients who left the operating room without primary sternal closure. Medical records were reviewed to determine mortality, postoperative complications, and pertinent hemodynamic data. Results. From November 1997 to June 2000, 5,177 adults underwent cardiac procedures at our center. The incidence of open chest management was 1.7% (87 of 5,177), including 0.7% (16 of 2,254) for isolated coronary artery bypass grafting, 1.6% (15 of 912) for isolated valve, and 5.6% (47 of 839) for combined valve/coronary bypass. Hospital survival was 76% (66 of 87). Major complications included deep sternal infection (n = 4), stroke (n = 8), and dialysis (n = 13). Predictors of mortality by univariate analysis included ventricular assist device insertion ( p = 0.003), new onset hemodialysis ( p < 0.0005), reoperation for bleeding ( p = 0.002), sternal infection ( p = 0.042), mean length of delay before sternal closure (survivors = 3.2 days, nonsurvivors = 6.2 days; p = 0.031), higher mean dose of epinephrine at the time of chest closure (2.5 μg versus 0.9 μg, p = 0.011), and longer duration of high dose inotropic therapy (110 hours versus 43 hours, p = 0.002). Multivariate analysis showed ventricular assistance and reoperation for bleeding as independent predictors of in-hospital death with odds ratios of 3.8 and 3.4, respectively. Conclusions. Liberal use of open chest management is useful in patients with postcardiotomy shock, and can be carried out with a relatively low incidence of sternal complications. Patients who require ventricular assistance or exploration for ongoing mediastinal bleeding continue to have a high mortality rate.

Delayed Sternal Closure after Cardiac Operations

In 1,459 open heart operations performed between July 1995 and March 2000, sternal closure was delayed in 30 patients (2%) because of hemodynamic instability limiting primary sternal closure in 12 and uncontrollable bleeding in 18. Two patients died in the immediate postoperative period while the chest was open, due to persistent low cardiac output secondary to myocardial failure. The sternum was closed in 28 patients at an average of 22 ± 0.3 hours (range, 8 to 48 hours) postoperatively. Two patients died in the late postoperative period prior to hospital discharge after sternal closure. Nonfatal wound infections occurred in 8 patients. The 26 survivors (86.7%) were discharged and followed up for a mean of 11.2 months. This study demonstrates that delayed sternal closure is an effective method of dealing with unstable hemodynamics and uncontrollable hemorrhage.

Primary sternal closure and mediastinal decompression by inlay autologous rib grafts

Hemodynamic instability and arrhythmia after cardiopulmonary bypass occasionally requires delayed sternal closure or placement of a stenting device. A primary sternal closure with autologous inlay rib grafts can ensure a secure, stable sternal repair and avoids prolonged ventilator support and the concerns, risks, and expense associated with a secondary sternotomy repair.

Open chest and delayed sternal closure after cardiac surgery

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. 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%). 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. 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.

Delayed sternal closure after neonatal cardiac operations

We retrospectively compared the use of primary elective open sternum coupled with delayed sternal closure with the use of primary sternal closure in neonates after cardiac operations. Primary elective open sternum/delayed sternal closure was selectively used in patients who demonstrated hemodynamic or respiratory deterioration, or both, during an intraoperative trial of sternal closure; otherwise primary sternal closure was used. Primary elective open sternum was used in 55 (61.8%) and primary sternal closure in 34 (38.2%) of the 89 patients studied. Eleven (20%) patients having primary elective open sternum died compared with 5 (14.7%) patients having primary sternal closure ( p = 0.6). Six (10.9%) of the patients with primary elective open sternum died before delayed sternal closure; the remaining 49 patients comprise the primary elective open sternum/delayed sternal closure group. The durations of mechanical ventilation (9.7 ± 0.9 days [mean plus or minus standard error of the mean], median 7.7 versus 9.9 ± 3.4 days, median 4.9; p = 0.0005) and hospital stay (21.1 ± 1.4 days, median 17.7 versus 19.6 ± 4.1 days, median 12.9; p = 0.004) were shorter in the primary sternal closure group. The overall morbidity and duration of inotropic support were not significantly different between the two groups, although seven (20.6%) of the patients with primary sternal closure did have to undergo delayed sternal reopening for refractory postoperative low cardiac output. There was one superficial wound infection in the primary elective open sternum/delayed sternal closure group. Primary elective open sternum/delayed sternal closure is an effective treatment for postoperative neonatal mediastinal compression for the following reasons: (1) the morbidity is low; (2) the mortality of the critically ill group of neonates in whom primary elective open sternum/delayed sternal closure was used was similar to that of the less critically ill primary sternal closure group; and (3) 20.6% of the primary sternal closure group eventually had to undergo delayed sternal reopening to treat refractory postoperative low cardiac output. (J THORAC CARDIOVASC SURG 1994;107:925-33)