Delayed Sternal Closure in Congenital Heart Surgery: A Risk-Benefit Analysis

  • Ahmed Abdelrahman Elassal Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
  • Osama Saber Eldib Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Egypt
  • Ahmed Mohamed Dohain Department of Pediatrics, Cairo University, Cardiology Division, Egypt
  • Gaser Abdelmohsen Abdelmohsen Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
  • Ahmed Hassan Abdalla Alahrar Teaching Hospital, Zagazig, Egypt
  • Osman Osama Al-Radi Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
DOI: https://doi.org/10.1532/hsf.2471
Keywords: Delayed - closure- congenital

Abstract

Background: Delayed sternal closure commonly is used after pediatric cardiac surgery. Its benefits include relieving cardiac compression and stabilizing postoperative critically ill patients.

Methods: We retrospectively reviewed the records of 72 patients, who had undergone delayed sternal closure, among 1,254 patients operated for congenital heart diseases. Indications of delayed sternal closure, perioperative hemodynamic and metabolic status, postoperative infection, and mortality were reported.

Results: Transposition of great arteries was the most common preoperative cardiac pathology (26.3%). Bleeding and hemodynamic instability were the most frequent indications for delayed sternal closure, representing 38.8% and 34.7%, respectively. The mean duration of open chest was 3.45 days ± 1.46 days. The mean duration of ICU stay was 20.95 days ± 20.06 days. Two patients had deep sternal wound infection. Sepsis was found in 39 patients (54.1%), and the most common causative organism was coagulase negative (30.5%). ICU stay was a significant risk factor for sepsis
(P = .003); duration of open sternum, period of mechanical ventilation (MV), and total hospital stay were not statistically significant risk factors. Sternal closure time (SCT) was affected by period of hemodynamic instability (P = .036). Bypass time, clamping time, and nonsurgical bleeding did not significantly affect SCT. The mortality rate was 15.2% (N = 11).

Conclusion: Delayed sternal closure is a simple and effective technique that could prevent postoperative cardiac compression in hemodynamic instability states after pediatric cardiac operations.

References

Alexi M V, Weng Y, Uhlemann F, Lange PE, Hetzer R. 1995. Prolonged open sternotomy after pediatric open heart operation: experience with 113 patients. Ann Thorac Surg 59:379-83.

Anderson CA, Filsoufi F, Aklog L, Farivar RS, Byrne JG, Adams DH. 2002. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. AnnThorac Surg. 73:1484-8.

Das S, Rubio A, Simsic JM, et al. 2011. Bloodstream infections increased after delayed sternal closure: cause or coincidence. Ann Thorac Surg 91:793– 8.

Edwards MS, Baker CJ. 1983. Median sternotomy wound infections in children. Pediatr Infect Dis 2:105-9.

Erek E, Yalcinbas YK, Turkekul Y, Saygili A, Ulukol A, Sarioglu CT. 2012. Indications and Risks of Delayed Sternal Closure After Open Heart Surgery in Neonates and Early Infants. World Journal for Pediatric and Congenital Heart Surgery 3(2) 229-235.

Fuchigami T, Nishioka M, Akashige T, Higa S, Nagata N. 2016. Staged delayed sternal closure using a binder clip after pediatric cardiac surgery. J Card Surg 31:464–466).

Furnary AP, Magovern JA, Simpson KA, Magovern GJ. 1992. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 54:233–239.

Göçen U. 2017. Delayed sternal closure after arterial switch operations: a single center experience. Cukurova Med J 42(3):540-545.

Harder EE, Gaies MG, Yu S, et al. 2013. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg 146:326-33.

Hurtado SD, Calderón CJ, Curi-Curi P et al. 2018. Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience. BioMed Research International, vol. 2018, Article ID 3742362, 6 pages.

Iyer RS, Jacobs JP, de Leval MR et al. 1997. Outcomes after delayed sternal closure in pediatric heart operations: A 10-Year Experience. Ann Thorac Surg 63:489 –91.5.

Johnson JN, Jaggers J,Li S, et al. 2010. Center Variation and Outcomes Associated with Delayed Sternal Closure Following Stage 1 Palliation for Hypoplastic Left Heart Syndrome. Thorac Cardiovasc Surg. May; 139(5): 1205–1210.

Nelsonm MK, Hornik CP, He X, et al. 2016. Delayed Sternal Closure in Infant Heart Surgery—The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 102:1565–72.

Özker E, Saritaş B, Vuran C, Yörüker U, Ulugö H, and Türköz R. 2012. Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study. Journal of Cardiothoracic Surgery 7:102.

Pollock EM, Ford JL, Rebeyka I, et al. 1990. Early nosocomial infections in pediatric cardiovascular surgery patients. Crit Care Med 18:378-84.

Riahi M, Tomatis LA, Schlosser RJ, Bertolozzi E, Johnston DW. 1975. Cardiac compression due to closure of the median sternotomy in open-heart surgery. Chest 67:113–114.

Riphagen S, McDougall M, Tibby SM, et al. 2005. “Early” delayed sternal closure following pediatric cardiac surgery. Ann Thorac Surg 80:678–85.

Samir K, Riberi A, Ghez O, et al. 2002. Delayed sternal closure:a life-saving measure in neonatal open heart surgery; could it be predictable. European Journal of Cardio-thoracic Surgery 21 787–793.

Tabbutt S., Duncan BW, McLaughlin D, Wessel DL, JonasRA. Laussen PC. 1997. Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg 113:886–893.

Woodward CS, Son M, Calhoon J, Michalek J, Husain SA. 2011. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice. Ann Thorac Surg. 91:799–804.

Yasa H, Lafcı BB, Yılık L, et al. 2010. Delayed sternal closure: an effective procedure for life-saving in open heart surgery. Anadolu Kardiyol Derg 10:163–167.

Published
2019-08-27
How to Cite
Elassal, A., Eldib, O., Dohain, A., Abdelmohsen, G., Abdalla, A., & Al-Radi, O. (2019). Delayed Sternal Closure in Congenital Heart Surgery: A Risk-Benefit Analysis. The Heart Surgery Forum, 22(5), E325-E330. https://doi.org/10.1532/hsf.2471
Issue
Vol 22 No 5 (2019)
Section
Articles

Author Disclosure & Copyright Transfer Agreement

In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.

A current form follows:

The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.

However, Publisher grants back to the author(s) the following:

  1. The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
  2. The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
  3. The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
  4. The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
  5. The right to make oral presentations of material from this work.

Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.

I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.

I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).

I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.

Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).