Asian Cardiovasc Thorac Ann 2001;9:82-85
© 2001 Asia Publishing EXchange Pte Ltd
Delayed Sternal Closure After Cardiac Operations
Mohammad Mubeen, MS,
Surajit Dan, MCh,
Surendra Kumar Agarwal, MCh,
Ashok Kumar Srivastava, MCh,
Vivek M Kanhere, MCh
Department of Cardiovascular and Thoracic Surgery
Sanjay Gandhi Post-Graduate Institute of Medical Sciences
Lucknow, Uttar Pradesh, India
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For reprint information contact: Ashok Kumar Srivastava, MCh Tel: 91 522 44 0963 Fax: 91 522 44 0017 email: ashok{at}sgpgi.ac.in Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India.
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Abstract
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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.
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Introduction
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Prolonged open sternotomy with subsequent delayed sternal closure (DSC) has been described as useful in the treatment of severe myocardial dysfunction, uncontrollable hemorrhage, and intractable arrhythmias.1–4 Prolonged open sternotomy can relieve cardiac compression and provide rapid access to control hemorrhage and arrhythmias; sternal closure can be carried out after the patient's hemodynamic status has stabilized.5,6 Most reports have included either a small group of patients or a single case. The only large series of patients (107) treated with DSC is that of Furnary and colleagues.7 This report describes our experience of 30 patients with DSC following open heart operations over a period of 5 years, with the aim of identifying the risks and assessing the outcome of this technique.
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Patients and Methods
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There were 1,459 patients who underwent open heart surgery at our institution between July 1995 and March 2000. Standard anesthesia, cardiopulmonary bypass, and surgical techniques were employed. For myocardial protection, cold crystalloid hyperkalemic cardioplegia was infused into the aortic root (or directly into the coronary ostia in cases of aortic valve surgery) in addition to topical hypothermia with ice slush. All patients received prophylactic antibiotics with a combination of cepha-losporin and aminoglycoside at induction of anesthesia and thereafter for 5 days postoperatively. The sternum was left open in 30 patients (2%), after the initial operation in 11, after the first reexploration in 10, and after a second reexploration in 9. There were 18 males and 12 females ranging in age from 6 to 72 years (mean, 58 ± 1 years). The primary operative procedures were coronary artery bypass grafting in 5, valve replacement in 14, coronary artery bypass and valve replacement in 3, intracardiac repair of tetralogy of Fallot in 5, total cavopulmonary connection in 2, and repair of an isolated perimembranous ventricular septal defect in 1. The operative procedures were classified as elective in 21 (70%), urgent in 7 (23%), and emergency in 2 (7%) patients.
Indications for DSC are given in Table 1
. Twelve patients were hemodynamically unstable, despite maximum inotropic support; 9 had markedly edematous ventricles that physically precluded primary sternal closure, and 3 became hemodynamically unstable in the intensive care unit after sternal closure and the sternum was reopened. Among 18 patients who had massive bleeding as a result of prolonged cardiopulmonary bypass and multiple blood transfusions, 8 left the operating room without sternal closure, 10 underwent reexploration and the sternum was subsequently left open.
During prolonged sternotomy, the wound was packed with sterile pads (in patients with intractable bleeding) and covered with a Steri-Drape plastic film (3M Healthcare, St. Paul, MN, USA). The dressing was changed frequently using a strictly sterile technique with povidone-iodine (ICI India Ltd, Derabassi, India). A fully sterile technique was used to inspect the cardiac activity and to irrigate the mediastinum. The sternum was kept open using a sterile retractor in cases of extreme myo-cardial edema or hemodynamic instability. The wound was then covered with Steri-Drape plastic film. The timing of sternal closure was determined by the level of pharma-cological support, correction of coagulation defects, improved hemodynamic parameters, and response to temporary reapproximation of the sternum. Sternal closure was routinely performed in the intensive care unit, thus avoiding the potential danger in transporting the critically ill patient. Debridement of all nonviable tissue and meticulous cleaning with Betadine solution were performed. Multiple bacterial cultures were taken from the chest wound. Two mediastinal drains were placed, as well as pleural drains when necessary. The sternum was rewired before closure of subcutaneous tissue and skin in a single layer.
All data for analysis was retrieved from a computerized database. Perioperative death was defined as death for any reason occurring within 30 days after the operation. Sternal, neurological, renal, and respiratory morbidity was compared. Sternal morbidity was defined as bac-teriologically confirmed superficial wound infection, mediastinitis, and sternal dehiscence necessitating refixation. Statistical analyses were carried out using the chi-squared test. A p value of < 0.05 was considered significant.
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Results
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In the DSC group, 4 patients died in the perioperative period, constituting the overall mortality rate of 13.3% (Table 2). Two of these deaths were due to persistent low cardiac output secondary to myocardial failure while the chest was open. The other 2 deaths occurred after sternal closure, due to intractable arrhythmias after double valve replacement and from neurological complications after intracardiac repair of tetralogy of Fallot. The 26 survivors were discharged from the hospital 10 to 35 days after sternal closure.
Respiratory complications defined as ventilatory support for more than 24 hours, occurred in 4 patients, of whom 2 had adult respiratory distress syndrome. Renal complications defined as a serum creatinine level above 20 mg•L–1, occurred in 7 patients, of whom 3 required peritoneal dialysis. Neurological complications defined as any transient or permanent neurological deficit occurring after the operative procedure, were noted in 2 patients with congenital heart disease who had undergone intracardiac repair. Three patients had upper gastro-intestinal hemorrhage that was controlled by medical measures. Two patients with multiorgan failure and 4 with septicemia subsequently improved. There were 4 patients with superficial wound infections after DSC (Table 2
). All were treated successfully with antibiotics and local debridement. Two patients developed medi-astinitis requiring mediastinal irrigation. Sternal de-hiscence was found in 2 patients, one of whom required sternal refixation. Sternal wound cultures grew organism in 8 patients, including Staphylococcus aureus in 4, Staphylococcus epidermidis in 3, and Enterococcus in 1.
The survivors were followed up for a mean period of 11.2 months. One patient was lost to follow-up. One patient developed sternal reinfection 6 months postoperatively, requiring removal of the sternal wires. The overall in-hospital mortality and sternal morbidity in the 1,429 patients who underwent primary sternal closure are summarized in Table 2.
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Discussion
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In the early days of cardiac surgery, primary closure of the chest was mandatory because of the fear of fulminant mediastinal infection. Recently, several reports have described DSC as a lifesaving procedure in patients with uncontrollable hemorrhage, myocardial edema, low cardiac output, and arrhythmias postoperatively.7–10 Restriction of diastolic filling is the main point at which there is disproportion in the cardiac to mediastinal relationship, leading to compression or tamponade, as described by Matsumoto and colleagues.11 Sternal closure has been shown to result in a significant decrease in cardiac output and diastolic filling, despite preserved velocity of fiber shortening, even in patients with good cardiac performance.12 These effects are magnified in the presence of poor ventricular compliance secondary to ischemia, reperfusion, and myocardial edema. Furnary and colleagues7 elegantly demonstrated that low cardiac output can be improved by opening the sternum. After the sternal incision had been reopened, there was a 59% increase in cardiac index and an 18% increase in systemic blood pressure without a significant change in cardiac filling pressures.
Severe bleeding on termination of cardiopulmonary bypass and excessive blood transfusion, and undue increases in heart size, resulting in severe ventricular dysfunction and arrhythmias are often associated with a prolonged perfusion time and poor myocardial preservation.12 DSC in these cases allows time for recovery of the heart and for the bleeding to stop, while totally isolating the myocardial structures from the outside environment. In addition, it provides easy access to the mediastinum for evacuation of blood clots, thus preventing cardiac tamponade.
Patients who required DSC were a higher risk group than the general population of patients undergoing open heart surgery. Most were in a severely compromised condition after the operation. They had an increased frequency of systemic complications such as renal failure, respiratory failure, multiorgan failure, and death. Although not statistically significant, those requiring DSC had a higher mortality rate than the patients not requiring DSC in this series. Mortality in this study was similar to that of other published reports.7,10,11 Prolonged cardiopulmonary bypass time, low cardiac output, excessive bleeding, and multiple blood transfusions are known to produce wound infections. The incidence of mediastinal infection after routine cardiac operations is reported to be greater than 1.5%.13 In this series, no statistically significant difference could be found in sternal morbidity between the DSC group and patients with primary sternal closure.
Many different techniques for the maintenance of an open sternotomy have been described.14–16 However, we preferred sterile packing and Steri-Drape coverage of the sternal wound. This method is easy to apply and provides rapid access to the mediastinum. It was concluded that delayed sternal closure is a useful adjunct in the treatment of persistent postoperative myocardial dysfunction and excessive bleeding. It can be applied with an acceptable morbidity and mortality when all attempts to optimize cardiac function have failed.
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References
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Abstract
Introduction
