Asian Cardiovasc Thorac Ann 2005;13:135-138
© 2005 Asia Publishing EXchange Ltd
Direct Complications of Repeat Median Sternotomy in Adults
Maqsood Elahi, MRCS,
Ramanarao Dhannapuneni, FRCS,
Richard Firmin, FRCS,
Mark Hickey, FRCSI
Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, United Kingdom
For reprint information contact: Maqsood M Elahi, MRCS Tel: 44 116 250 2687 Fax: 44 792 901 0164 Email: manzoor_elahi{at}hotmail.com, Department of Cardiac Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, United Kingdom.
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ABSTRACT
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Whilst the potential risk to underlying vital structures from redo-sternotomy is well recognized, the actual risk is poorly quantified. Our aim was to determine the incidence of complications directly attributable to redo-sternotomy and to ascertain whether the use of femoro-femoral CPB (FF) prior to redo-sternotomy alters operative morbidity and mortality. Case notes of 185 patients undergoing cardiac surgery necessitating redo-sternotomy between May 1998 and November 2002 were reviewed. Of 121 males and 64 females, the median age was 65.5 years (range 60.1–75 years). Elective FF was performed in 71 (38.3%) of cases and 114 (60%) were performed without the aid of prior femoro-femoral CPB (WFF). Three (1.6%) patients initially planned for WFF were converted to emergency FF due to serious complications. Complications directly attributable to redo-sternotomy occurred in 21 (11.3%) cases; 12 (16.9%) in the FF group and 9 (5.3%) in the WFF group. Overall mortality was 1.6%. In summary, our results suggest that morbidity risk for the operation increases significantly with redo-sternotomy alone. Three deaths in our series from direct complications attributable to redo-sternotomy signify an added risk. Hence the necessity for careful surgical technique and judicious use of elective FF-CPB is emphasized.
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INTRODUCTION
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With advances in cardiac surgery over the last 15 years, survival has markedly improved. However progression of disease as well as failure of conduits and prosthetic valves has necessitated re-operation in up to 15–20% of all heart operations.1,2 Sternal re-entry poses a risk of damage to vital structures. Serious complications, such as uncontrollable hemorrhage, dislodgement of thrombo-emboli, damage to previous conduits and neo-intimal collapse can occur during the initial dissection2,3 which may necessitate immediate institution of cardiopulmonary bypass through the femoral vessels.4,5 These specific problems increase perioperative morbidity and mortality especially in the pediatric population; however, information in adults undergoing repeat surgery is scarce. This is a report of our experience in adult patients undergoing repeat cardiac operations to determine the incidence of complications directly attributable to redo-sternotomy, and to ascertain whether the use of femoro-femoral cardiopulmonary bypass (CPB) prior to redo-sternotomy has any affect on perioperative mortality and morbidity.
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PATIENTS AND METHODS
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Between May 1998 and November 2002, 185 patients who underwent repeat sternotomies were studied. There were 121 males and 64 females. The median age was 65.5 years (range 60.1–75 years) and the overall mortality was 1.6% (3 patients). One hundred and fourteen (60%) redo-operations were performed without the aid of prior femoro-femoral CPB (WFF group) and 71 (38.3%) with femoro-femoral CPB (FF group). Three (1.6%) patients initially planned for WFF were converted to emergency FF due to serious complications encountered during redo-sternotomy. The initial surgical procedures were aortic valve replacements (AVR) in 28 patients, mitral valve repair/replacement (MVR) in 37 patients and coronary artery bypass grafting (CABG) in 120 patients. Re-operations included AVR in 38 patients, MVR in 40 patients, tricuspid valve replacement (TVR) in 5 patients, pulmonary valve replacement (PVR) in 1 patient, MVR and TVR in 15 patients, aortic valve and ascending aorta surgery in 3 patients, combined AVR and MVR in 8 patients, CABG in 63 patients, combined MVR and CABG in 6 patients, AVR and CABG in 6 patients.
SURGICAL PROCEDURES
Most patients underwent operations with moderate hypothermia and cardioplegic arrest. Deep hypothermia and circulatory arrest was used only in repair of ascending aorta. Elective FF-CPB before repeat sternotomy was used in 71 patients and 3 patients were put on FF-CPB as an emergency. The criteria for FF-CPB were preoperative judgement and surgeon preference.
STATISTICAL ANALYSIS
Data were expressed as median and range for all descriptive variables. The Wilcoxon rank-sum test was used to test for equality of the median values. Actuarial data for survival was analyzed using Kaplan-Meier estimates. A value of p < 0.05 was taken as significant.
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RESULTS
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Table 1
outlines the clinical and operative demographics of patients undergoing redo-sternotomy. Complications directly attributable to redo-sternotomy occurred in a total of 21 (11.3%) cases; 12 (16.9%) in the FF group and 9 (5.3%) in the WFF group. These comprised of minor injuries to the aorta 9 (4.8%), right ventricle 6 (3.2%), right atrium 2 (1.0%), previous saphenous vein grafts 1 (0.5%), previous internal mammary artery grafts 1 (0.5%), the right lung 1 (0.5%) and uncontrollable hemorrhage from a tear in the aorta 1 (0.5%). There were 3 (2.6%) deaths reported in the WFF group (Table 2).
There were no significant differences noted in terms of low cardiac output, sepsis, and period of ventilation between the two groups. The incidence of transient ischemic attack (TIA) ( p = 0.032), renal failure ( p < 0.01), postoperative bleeding ( p < 0.05), and bypass time ( p < 0.05) was higher in WFF patients in contrast to their counterparts (Table 1
). However, the incidence of arrhythmia ( p < 0.001) was higher in the FF group (Table 3).
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DISCUSSION
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The number of cardiac re-operations is steadily increasing. Among the various risks these patients are exposed to are the risks of sternal re-entry and major bleeding. Reports in the literature of complications of sternal reentry are limited, so the prevalence varies greatly. Lytle and colleagues6 reported 3 deaths among 1500 coronary re-operations due to complications of repeat median sternotomy whereas Macmanus and colleagues7 reported 8 cases of severe hemorrhage in 122 repeat sternotomies. The risk of injury to a patent internal thoracic artery graft has been reported in 2 series: one by Lytle et al8 reporting damage in 3.5% of 489 patients, and 1 by Baillot et al9 reporting a rate of 8% among 100 cases.
Culliford and Spencer10 in a review of their experience, stated that the most common reasons for complications were lack of precise technique and insufficient attention to hemostasis. In the most recent report of Dobell and Jain11, it is evident that repeat median sternotomy remains a major challenge to cardiac surgeons. Our series demonstrated that cardiac structures were injured 21 times at repeat sternotomy. There were two major injuries to the aorta and one to the right ventricle for which emergent institution of femoro-femoral bypass was undertaken. There were three deaths out of 185 cases; one catastrophic tear in a conduit coursing underneath the sternum, with concomitant right ventricular tear and simultaneous ventricular fibrillation; one uncontrollable hemorrhage from a tear in the aorta and 1 incident of damage to an innominate vein. All these occurred in the WFF group although in the latter two cases, FF institution was undertaken on an emergency basis.
Several surgical approaches are available to patients undergoing repeat operations. For example, dissection on the beating heart in the non-heparinized patient can be achieved starting from caudally subxiphoid (by using a hook or Rultract retractor) to craniad, with the patient in the Trendelenburg position using scissors (starting with short and subsequent increasingly long scissors). The surgeon may then cut the sternum using the ordinary saw. This allows a dry, clean and safe alternative technique allowing routine CPB to be established. Cardiopulmonary bypass can be accomplished through the femoral vessels followed by redo-sternotomy, or redo-sternotomy can be initially performed with CPB instituted through the femoral vessels in the event of difficulties. Macmanus and associates reported institution of CPB through the femoral vessels prior to repeat sternotomy in certain instances.7 In accordance with others,10,11 our experience suggests that a calcified conduit behind the sternum and lack of retrosternal space were the main risk factors for sternal re-entry.
Although the overall mortality in the redo operation group reported in the literature6,10 is 13.8%, our series has demonstrated a 30-day mortality of 1.6% following re-entry sternotomy. The incidence of direct complications may have been higher in our series but the judicious employment of FF had influenced our results as preparations for FF were made electively due to the possibility of inadvertent entry into the heart or great vessels when the sternum was divided.
Some groups maintain that repeat median sternotomy may be facilitated by certain maneuvres at the time of the initial cardiac procedure. Cliff and associates12 showed that both serosal injury and blood are necessary to produce cardiac adhesions. Careful handling of the heart and complete evacuation of pericardial blood may reduce postoperative adhesions. Where appropriate, approximation of the pericardium or placement of synthetic biomaterials may also facilitate re-operation.
A significant limitation of our study relates to the fact that repeat sternotomy is only 1 parameter of outcome in redo cardiac surgery. Clinical results are more likely to depend on the complexity of the primary diagnosis and the procedure as well as the quality of the surgical repair. Moreover, information regarding the number of patent internal thoracic arteries (ITA) following the primary CABG and likelihood of local morbidities relating to trauma to the femoral vessels due to FF bypass have not been quantified due to the retrospective, observational nature of this study.
The main question surgeons confront is whether re-operations have an incremental effect on operative mortality compared with primary procedures. Although the literature13,14 has shown a varied trend towards complications in the repeat sternotomy group, in summary our series has demonstrated that repeat sternotomy carries added risks to the operation, which could be improved with an organized surgical approach and judicious use of elective femoro-femoral bypass. In addition, as suggested in previous studies,7,9 a lateral chest X-Ray or CT scan may be useful in determining the likelihood and extent of adhesions between the heart, great vessels and the sternum.
Presented at the Scientific Exhibition at the 89th Clinical Congress of the American College of Surgeons in Chicago, Illinois, USA.
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ACKNOWLEDGMENTS
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The authors gratefully acknowledge the assistance of Mrs Karen Jack, Audit Planning and Performance Manager and Mrs Jo Harding, Manager Medical Records in Cardiac Surgery at the Glenfield Hospital, Leicester, United Kingdom.
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REFERENCES
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ABSTRACT
INTRODUCTION
