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Ann Thorac Surg 1995;60:387-391
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Sternal Traction After Open Heart Operation: An Effective Alternative to Delayed Sternal Closure

Department of Cardiovascular Surgery, Kaiser-Permanente Medical Center, San Francisco, California, and Department of Cardiovascular Diseases, Midelfort Clinic Ltd, Eau Claire, Wisconsin

Accepted for publication April 3, 1995.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Background. Routine closure of the sternum after cardiovascular surgical procedures sometimes causes severe cardiac depression because of a tamponade-like reduction in ventricular filling, leading to cardiogenic shock. Leaving the sternal halves apart, sealing the mediastinum by simply approximating the skin or using a prosthetic patch, and then performing delayed sternal closure in several days is a widely practiced life-saving maneuver.

Methods. Described herein is an experience with 5 patients with severe cardiac output depression of the type usually treated by delayed sternal closure. Instead, upward (outward) traction was applied to the anterior chest while the sternum was primarily closed. Traction was maintained with full-thickness chest wall sutures.

Results. The traction sutures were removed successfully in the intensive care unit between 1 and 4 days postoperatively, after appropriate vigorous treatment of postbypass myocardial enlargement and pulmonary distention and edema.

Conclusions. This method of sternal traction allows physiologic improvement equivalent to delayed sternal closure in some patients and obviates the need for returning to the operating room to close the sternum in the early postoperative period.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Routine closure of the median sternotomy incision in cardiac surgery is sometimes impossible because of severe compression of the heart by the lungs and chest wall, leading to life-threatening low cardiac output and hypotension. Multiple authors have pointed out the dangerous combination of right ventricular failure/enlargement and sternal closure, especially after operations for congenital heart disease, and have described ``delayed sternal closure'' (DSC) as a life-saving alternative, creating a closed mediastinal environment by simply approximating the skin edges [1–7]. Closing an open sternotomy with woven Dacron patches [8], adhesive plastic drapes [9], Esmarch bandage [10], silicone sheeting [11–13], expanded polytetrafluoroethylene [14], or impermeable rubber [15] also has been practiced successfully with good results in preventing mediastinal infection while cardiac and pulmonary edema resolve over several days, ultimately allowing formal sternal closure with wire approximation of the minimally debrided sternal halves. Josa and associates [10] and Mestres and colleagues [14] also used iodine-povidone–soaked gauzes to pack the mediastinum of patients with uncontrolled postoperative bleeding and covered the gauze packs with a variety of synthetic membranes until returning the patients to the operating room to remove the packs and close the sternum. Recurrent ventricular fibrillation, presenting the need for repeated resuscitation and cardioversion, has been mentioned by Fanning and associates [3] and Gielchinsky and co-workers [9] as another reason for DSC. Ugorji and colleagues [16] used DSC in patients requiring trans–ascending aortic balloon insertion, and insertion of ventricular assist device cannulas frequently is accompanied by the inability to close the sternum [17]. In severe cases of cardiac dysfunction complicated by pressure of the sternum and chest wall on the heart, a variety of devices to keep the sternal halves separated, including rib grafts [18], methyl methacrylate [19], plastic struts [4], metal struts [11], slotted chest tubes [7], ``tailored syringes'' [20], hydroxyapatite blocks [21], Lyodura membrane [22], and even sternal spreaders [3, 17], have been used to protect the heart from the excessive pressure of the chest wall components. The devices are removed when cardiopulmonary volumes and function return to normal, and the sternum then is closed secondarily, although Baumgart and associates [21] completely closed the soft tissues primarily over hydroxyapatite blocks, which acted as permanent implants, with ossification of the implants as early as 2 months after insertion.

In 1975, Riahi and associates [23] described a patient in whom they attached the top and bottom sternal wires to a traction device to relieve severe depression of cardiac function experienced with repeated attempts at standard closure of the chest. This method also required returning the patient to the operating room to remove the traction wires and reclose the sternotomy. Matsuki and colleagues [24] recently published experience with more than 40 pediatric patients using transmural 3-0 Nylon sutures attached to traction to relieve cardiac compression after repair of congenital defects. The present report describes our experience in 5 adult patients with an alternative method of primary sternal closure with traction using full-thickness parasternal no. 6 wires or heavy Nylon sutures, placed so they can be removed in the intensive care unit, obviating the need to return the patient to the operating room for either removal of the traction wires or formal DSC.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
This 51-year-old man underwent redo coronary artery bypass grafting in March 1988. The operation was complicated by right coronary saphenous vein graft atheroembolism and incomplete revascularization. The patient was weaned from bypass with atrioventricular pacing and dopamine support. When the sternotomy was closed, the mean left atrial pressure rose from 15 to 30 mm Hg, and cardiac output and systolic arterial pressure dropped precipitously. The sternum immediately was reopened, with return of the patient's hemodynamic parameters to normal. The lungs were chronically hyperinflated. All bypass grafts functioned well and were not kinked. Repeated attempts to close the sternum met with identical results, in spite of adding dobutamine and epinephrine infusions. The problem was thought to be a mismatch between the sizes of the edematous ``stunned'' heart and the mediastinal space. We recognized that when the crossed, but untied, sternal wires were pulled upward vigorously, the patient's condition improved significantly. Therefore, two full-thickness no. 6 parasternal wires were placed in the first and fifth interspaces and retracted upward while the standard sternal wires were tied successfully and the soft tissues quickly closed in a routine fashion. The patient was transferred to a bed containing an orthopedic frame, and traction (11.25 kg) was placed on each of the transmural wires (Fig 1).

View larger version (134K): [in this window] [in a new window]   Fig 1. . Traction arrangement with 11.25 kg applied to each of the two transmural no. 6 stainless steel wires.

Patient 2
This 64-year-old obese diabetic woman with a rigid chest wall and massive breasts underwent quadruple coronary artery bypass grafting in April 1991. After routine weaning from cardiopulmonary bypass, while monitored by continuous transesophageal echocardiography (TEE), closure of the sternum caused dramatic reduction in the patient's systolic arterial pressure and cardiac output, and the TEE demonstrated marked inferior segmental wall motion abnormalities. The sternum was reopened, and all indices of cardiac function immediately returned to normal. There was no mechanical problem with the grafts. When the wires were replaced and the sternum was closed a second time, cardiogenic shock developed again. After a second check for any mechanical problem with the grafts, inferior and superior full-thickness wires were placed. The sternal wires were reinserted in the usual fashion and tied while the assistant retracted the parasternal wires upward. The wound was closed, and the patient was transferred to a bed with 11.25 kg of traction on each of the wires. Over the first day, any reduction in the traction led to immediate depression of the cardiac output and systolic pressure. After 20 hours, the individual traction weights were weaned relatively quickly, and the wires were removed aseptically in the intensive care unit on the second postoperative day. A late sternal wound infection did develop, requiring treatment with a muscle flap. The patient recovered without further complications.

Patient 3
This 65-year-old woman with severe peripheral vascular disease and marked chronic obstructive pulmonary disease, secondary to nicotine addiction, had three-vessel coronary disease, including left main coronary artery stenosis, and ventricular diastolic dysfunction. At operation in August 1991, the patient's lungs were grossly overdistended. A triple coronary bypass procedure was performed. The distal right coronary artery and posterior descending artery were too small to bypass. As attempts were made to separate the patient from cardiopulmonary bypass, TEE demonstrated global hypokinesia. An intraaortic balloon pump (IABP) was inserted, and the patient was weaned from bypass with IABP, dobutamine, epinephrine, and amrinone support. The sternum was quite flimsy, and no. 5 Tycron figure-of-8 sutures were used. When the sternum was closed, however, the patient's ventricular function (TEE and hemodynamic parameters) deteriorated. The sternum was reopened immediately, and all functional measurements returned to normal. Three no. 2 Nylon sutures were passed transmurally through the first, third, and sixth intercostal spaces and pulled upward, while the sternum was closed again with Tycron sutures. The patient was transferred quickly to an orthopedic bed, where 6.75 kg of traction was applied to each of the Nylon sutures. The IABP was removed 2 hours later because of ischemia of the right leg. The patient continued to improve hemodynamically. Traction was slowly weaned between 24 and 72 hours postoperatively, and the Nylon sutures were removed. Echocardiography showed inferior wall hypokinesis. The patient could not be separated successfully from the ventilator, and a tracheostomy was performed. She was weaned slowly from mechanical ventilation over the ensuing 5 weeks and discharged.

Patient 4
This 73-year-old man underwent repeat quadruple coronary artery bypass grafting in February 1992. Harvesting of the left internal mammary artery was especially difficult because of dense adhesions between the left lung, the heart, and the chest wall. The patient was weaned from bypass with no pressors required and with good ventricular function (TEE). The left internal mammary artery appeared to be stretched by the hyperinflated left lung, however, so it was dissected further off the hyperinflated lung, and six fasciotomies of the pedicle were performed [25]. The left lung still distorted the left internal mammary artery after this maneuver, so the residual left leaf of the pericardium was sutured to the chest wall near the midclavicular line with nonabsorbable pericostal sutures to exclude the lung from the mediastinum.

When the sternum initially was closed, the patient became hypotensive (70/35 mm Hg), and, by TEE, the left ventricle appeared hypovolemic. Blood pressure and cardiac output did not respond to rapid transfusion, and the sternal wires were untied. The patient recovered well. After a second attempt to cross the sternal wires led to an identical result, two transmural wires were placed as before, and the sternal incision was closed quickly and the patient transferred to a traction-providing bed. Traction was slowly reduced after 24 hours, while the patient was ventilated with low tidal volumes, and the wires were removed on the second postoperative day. The patient recovered with no further untoward cardiovascular events.

Patient 5
This 67-year-old hypertensive, diabetic woman had development of atypical chest pain in the hospital while awaiting a cholecystectomy in September 1994. Electrocardiography showed marked ischemic changes, and aspirin, heparin, and nitroglycerin were given. Echocardiogram revealed reduced wall motion of the distal septum, apex, and anterior wall of the left ventricle. Cardiac catheterization showed a large akinetic anteroapical region, which had the appearance of an acute aneurysm, plus severe multivessel disease, with a complex left anterior descending coronary artery lesion precluding angioplasty, and significant circumflex stenosis. By this time she was in cardiogenic shock and was taken quickly to the operating room, where vein grafts to the left anterior descending, diagonal, and circumflex marginal coronary arteries were constructed. After the cross-clamp was removed, there was massive reperfusion hemorrhage of the akinetic area in the distribution of the left anterior descending and diagonal coronary arteries. There was a 3-cm step-up in the epicardial surface from the anterior right ventricle to the anterior wall of the left ventricle. She had many reperfusion arrhythmias. The patient was weaned from bypass with IABP, amrinone, and epinephrine support. It was impossible to remove the sternal retractor because the left hemisternum compressed the dilated left ventricle, causing worsening regional wall motion abnormalities (TEE) and shock. Dobutamine administration was started. The patient still would not tolerate closure of the sternum. Therefore, two full-thickness wires were placed and retracted upward, while the sternum was approximated in routine fashion with wires, and the soft tissue was closed in a normal manner. After 14 hours in the intensive care unit, the patient's reperfusion ventricular arrhythmias subsided, and the traction was weaned in 4.5-kg decrements over the ensuing 10 hours, the wires being removed 24 hours postoperatively. The IABP was removed shortly thereafter. The patient was discharged doing well.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
Life-threatening cardiac compression from sternal closure after open cardiac operations is uncommon, occurring with a frequency of 1.2% to 2.8% [3, 5, 9, 10, 13, 14, 17] in series of adult patients treated by DSC to avert certain death if standard closure techniques were pursued relentlessly. The frequency of such cardiac compression in neonates and children has been reported as high as 30% [12]. The pathophysiologic reasons behind this tamponade-like depression of cardiac function vary, but the basic problem is a mismatch between the size of the heart and the space that the chest wall, lungs, and pericardium leave for the heart to inhabit once the continuity of the chest wall is reestablished by sternal union. The syndrome of low cardiac output and hypotension has been called ``squeezed-heart'' syndrome [9], cardiomediastinal disproportion [3], tight mediastinal syndrome [23], or atypical tamponade [7, 26]. Closure of the sternum has been shown by physiologic methods [26] and echocardiography [27] to cause reduction in cardiac performance ranging in severity from trivial to life-threatening. The neonate or infant with a right ventriculotomy and pulmonary regurgitation is at the highest risk for cardiogenic cause of the mismatch [7]. Laver and associates [28] demonstrated the interdependence of the right and left ventricles in the presence of intact ``pericardiac'' space limitations in acute respiratory failure. Increased right ventricular end-diastolic volume required for normal right ventricular output after right ventriculotomy or after right ventricular infarction [29] affects the left ventricle by decreasing left ventricular compliance and filling. The TEE appearance of left ventricular hypovolemia has been documented by Matsumoto and colleagues [27] as a decrease in end-diastolic dimensions without any change in fractional shortening. Jögi and Werner [30] studied 8 children after various intracardiac repairs and showed that sternal closure adversely affected cardiac output, arterial pressure, and the normal end-diastolic pressure–volume relationship. All authors reported hemodynamic improvement with either incision of the pericardium or reopening of the sternal incisions.

The restrictive capabilities of the pericardium and chest wall are significantly complemented by overexpanded or ``stiff'' lungs, which compete with the heart for primacy in the defined, contained space of the closed thoracic cavity. In cases of fulminant noncardiogenic pulmonary edema [2], severe air trapping, or mechanical overdistention of the lungs by the ventilator, the heart, which is intrinsically depressed by cardiopulmonary bypass itself [31] or an ischemia-related wall motion abnormality, often will lose to the lungs in this biological territorial dispute.

Misawa and associates [32] proposed criteria for DSC; they suggested DSC if the right or left atrial pressure increased more than 2 mm Hg when the sternum was closed ``tentatively.'' In general, however, this degree of ``atypical tamponade'' generally can be treated by drugs or volume infusion; it usually improves spontaneously over a short period of time as ventricular accommodation generally allows the cardiac parameters to return toward preclosure levels.

However, in a small but defined number of post–cardiopulmonary bypass patients, especially those with ``stunned'' myocardium or poor ventricular function from other causes, standard sternal closure will cause lethal cardiac compression. Delayed sternal closure is an accepted, widely practiced interim method of treating this life-threatening event if IABP and pharmacologic therapy are not effective. Not joining the sternal halves enlarges the space available for the heart and the lungs. Closing only the soft tissue primarily or using a prosthetic device to establish a barrier against infection has been quite effective in preventing mediastinitis, but both techniques require returning the patient to the operating room for formal closure of the sternum after reopening of the skin or removal of the prosthetic membrane (and the separating implements, if applicable).

The thoracic volume also can be increased by traction on the sternum. Among the 5 patients in this series, 1 had transient myocardial depression alone, 2 had large nonbypassed areas of ischemic myocardium, 2 patients' myocardial stunning was complicated by stiff overexpanded lungs, and 1 patient had significant enlargement of the left ventricular mass caused by reperfusion hemorrhage of the anterior-apical muscle and epicardial fat. Either increasing the total space available to the lungs and heart or simply relieving the downward pressure of a stiff chest wall (complicated in patient 2 by heavy, pendulous breasts) by applying 18 to 27 kg of upward traction delivered through transmural wires was adequate to allow standard sternal approximation. We also now practice and strongly suggest the technique of controlled hypoventilation or permissive hyperpnea to prevent overdistention of diseased lungs with the attendant cardiac compression [33].

In each of these 5 patients, early postoperative release of traction was associated temporarily with worsening of cardiac function. After intervals of 14 to 72 hours, during which time vigorous diuresis and inotropic therapy helped to reduce pulmonary and myocardial edema, the traction was weaned progressively and the wires were removed aseptically in the patient's intensive care unit bed, without a return trip to the operating room. All of the patients survived, although 1 diabetic woman had development of a late sternal infection, treated successfully by our protocol of aggressive sternal debridement and closure of the wound with pectoral flap(s).

This universal success with the traction method of increasing static thoracic volume, reinforced by Matsuki and associates' [24] large pediatric experience, prompts our suggesting sternal traction as an easy, quick, and safe alternative to DSC. Use of sternal traction as a secondary procedure also may allow earlier secondary closure of the sternum in patients who have required DSC after cardiac surgical procedures, in whom traction initially did not offer enough relief.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Dr McEnany, Midelfort Clinic Ltd, 1221 Whipple St, Eau Claire, WI 54702-4105.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): M. Terry McEnany Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McEnany, M. T. Search for Related Content PubMed PubMed Citation Articles by McEnany, M. T.