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Ann Thorac Surg 1997;63:489-491
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Outcomes After Delayed Sternal Closure in Pediatric Heart Operations: A 10-Year Experience

Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Trust, London, England

Accepted for publication September 16, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Open heart operations in young children may lead to myocardial swelling and increased lung water. Decreased intrathoracic space may then make sternal closure difficult. Delayed sternal closure may be beneficial in this setting. Potential risks of delayed sternal closure are sepsis and sternal instability.

Methods. To assess these risks, we reviewed retrospectively 150 consecutive children who underwent delayed sternal closure after repair of complex congenital cardiac defects.

Results. Diagnoses included transposition of the great arteries (66), total anomalous pulmonary venous drainage (11), and complete atrioventricular septal defects (10). Age at operation was 229 ± 51 days (mean ± standard error of mean). Sixteen patients required extracorporeal membrane oxygenation. Survival was 88% (133 patients). The sternum was left open for 3.86 ± 0.29 days. Fifteen patients had minor wound infections requiring antibiotics. No patient required reexploration for mediastinitis and no patient had an unstable sternum.

Conclusions. Delayed sternal closure with sternal stenting and silicone membrane skin closure is a safe procedure in infants and children with compromised cardiac output after repair of congenital cardiac defects.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Compression of the heart by its surrounding structures can limit the end-diastolic volume of the ventricles and in turn lead to a decrease in cardiac output [1]. This problem may be seen particularly after open heart operations in young children, in whom myocardial swelling and increased lung water add to the limitation of intrathoracic space. Sternal closure at this stage may cause additional cardiac compression. In addition to myocardial edema, poor hemodynamic indices, primary pulmonary problems, arrhythmias, unsatisfactory hemostasis, and cardiac assist devices also may prevent primary sternal closure after open heart operations.

Various methods have been reported to avoid primary sternal closure. These techniques offer flexibility in supporting the patient during the difficult immediate postoperative period in both adult [2–7] and pediatric [8–12] open heart procedures. Potential risks of delayed sternal closure include sepsis, mediastinitis, bleeding, and late sternal instability.

To define the incidence of these risks, we reviewed retrospectively 150 consecutive patients who underwent delayed sternal closure after repair of complex congenital cardiac defects.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
Among 3,718 open heart operations, 150 patients (4.03%) underwent delayed sternal closure at the Great Ormond Street Hospital for Children, NHS Trust, London, between January 1986 and December 1995. Data pertaining to these patients were reviewed retrospectively. Age at operation was 229 ± 51 days (mean ± standard error of the mean), and the median age was 21 days. Weight at operation was 4.8 ± 0.3 kg (median, 3.5 kg).

Diagnoses included transposition of the great vessels (66, 44%), total anomalous pulmonary venous drainage (11, 7.3%), complete atrioventricular septal defect (10, 6.6%), truncus arteriosus (9, 6%), tetralogy of Fallot (9, 6%), combined ventricular septal defect and atrial septal defect (4, 2.6%), hypoplastic left heart syndrome (4, 2.6%), interrupted aortic arch (2, 2%), reoperations (24, 16%), and others (11, 7.3%). The patients who had undergone reoperation had prior open heart procedures (10), repair of coarctation of the aorta and pulmonary artery banding (5), modified Blalock-Taussig shunts (5), and pulmonary artery banding alone (4).

Indications for Delayed Sternal Closure
ELECTIVE.
Poor cardiac performance after cardiopulmonary bypass (indicated by blood pressure, filling pressures, and blood gases) accounted for 68 (45.3%) of the patients. These patients demonstrated poor cardiac performance before any attempt at sternal closure.

CARDIAC COMPRESSION ON ATTEMPTED CLOSURE.
In 35 patients (23.3%), sternal approximation led to a decrease in blood pressure and a rise in filling pressures, indicating compression of the heart. This led to eventual stenting of the sternum.

PULMONARY PROBLEMS.
Pulmonary problems occurred in 10 (6.7%) of the patients and included suboptimal ventilation requiring high inflation pressures (7), nondeflatable lungs at end expiration (2), and intrapulmonary hemorrhage (1).

ARRHYTHMIAS.
Unstable cardiac rhythm was the indication for delayed sternal closure in 8 (5.3%) of the patients.

BLEEDING.
Eight children (5.3%) had their sternum left open because of difficult or unsatisfactory hemostasis, combined with a risk of tamponade if the sternum were to be closed primarily.

ACCESS.
Sixteen patients (10.7%) required extracorporeal membrane oxygenation after failing to wean satisfactorily from bypass; the sternum was kept open to provide space for aortic and atrial cannulation. One patient had the chest splinted open to allow placement of an arterial pressure monitoring line from the ascending aorta, because repeated attempts at peripheral access failed.

MISCELLANEOUS INDICATIONS.
These included 5 patients (3.3%), 3 of whom had ischemic changes on the electrocardiogram despite a good cardiac output and 2 of whom had high pulmonary artery pressures with complete heart block.

Method of Sternal Closure
All of the patients undergoing delayed sternal closure had their sternum stented open with one or two pieces of polyvinyl chloride tube. The tube was fashioned so that grooves cut at the ends fit the sternal edges. The stents were then fixed to the sternum with a nonabsorbable suture. Two different techniques were used for closure. Early in the series, skin flaps were developed and the skin was closed primarily over the stented sternum. Later in the series, the wound was closed using a transparent silicone membrane (Osteotec Ltd, Christchurch, Dorset, UK) sutured to the skin edges.

The chest drains and pacing wires came through separate sites from the chest. In the patients having extracorporeal membrane oxygenation, the cannulas exited through the main wound under the silicone membrane. Irrigation of the mediastinum was not performed.

All patients were electively sedated, paralyzed, and ventilated while the sternum was open. Once the patients were deemed hemodynamically stable with optimum ventilation, stable rhythm, and minimal drainage, the inotropic agents were partially weaned. The stents and silicone membrane were removed, and the sternum was closed. Those having extracorporeal membrane oxygenation were weaned off their support and were decannulated. Sternal closure was subsequently attempted. All of the patients remained in the intensive care unit. Sternal closure was performed in the intensive care unit according to our standard protocols. After sternal closure was achieved, the children were weaned from their ventilators and extubated.

All patients received antibiotic therapy (penicillin and an aminoglycoside) up to the time of sternal closure, after which all antibiotics were stopped. The mediastinum was lavaged with a clear crystalloid solution at sternal closure.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Postoperative Course
The patients had an open sternum for 3.86 ± 0.29 days (mean ± standard error of the mean), with a range of 1 to 33 days. Twenty-five patients (16.7%) were extubated within 24 hours of sternal closure. The overall duration of ventilation was 6.2 ± 0.96 days (range, 2 to 101 days) after sternal closure. The numbers of days in the hospital were 21.5 ± 1.6 after operation and 17.6 ± 1.6 after sternal closure.

Thirty-one patients (20.6%) required exploration in the intensive care unit before sternal closure. Twenty-five of these patients were reexplored for bleeding; we used published criteria for reexploration of the chest for bleeding [13]. Four children had reexplorations for low cardiac output, and 2 had pacing-wire problems.

Mortality
There were 17 deaths (11.3%). Causes of death were pulmonary hypertensive crisis (7), multiorgan failure (6), right ventricular failure (2), arrhythmia (1), and thrombolytic therapy for a large right atrial clot (1). The primary diagnoses of the patients who died were transposition of the great vessels (5), tetralogy of Fallot (3), truncus arteriosus (3), complete atrioventricular septal defect (1), hypoplastic left heart syndrome (1), ventricular septal defect with coarctation of the aorta (1), double inlet left ventricle (1), Ebstein's anomaly (1), and congenital mitral stenosis with patent ductus arteriosus (1). No patient died of sepsis.

Morbidity
Fifteen patients had minor subcutaneous wound infections after closure. These were treated with antibiotics alone. No patient required reexploration for mediastinitis, and none had sternal instability after closure. Four patients required tracheostomy before being weaned off the ventilator. Eight of the 16 patients requiring extracorporeal membrane oxygenation died. The remaining patients underwent decannulation followed by sternal closure the next day.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Prolonged open sternum with delayed sternal closure after open heart operations in adults has been universally acknowledged [2–7]. The usefulness of delayed sternal closure after pediatric cardiac operations also has been reported [8–12]. In a comparative analysis, Hakimi and associates [14] concluded that delayed sternal closure is an effective treatment for clinically significant postoperative mediastinal compression after heart operations in neonates.

Various methods of delayed sternal closure have been used, including maintaining the sternum open with a self-retaining retractor [3], mediastinal packing [15], Steridrape (3M Health Care, St. Paul, MN) film coverage [6], silicone membrane [7], and primary skin closure [4]. Closure of the skin alone using silicone elastomer sheeting also has proved useful in neonates [10]. Shore and colleagues [11] used a piece of stent fashioned from an Argyle chest drain to splint the open sternum.

Our current method uses a stent of polyvinyl chloride tube, which is readily available from the -inch or -inch tubing of the bypass circuit. The skin is then closed with a silicone membrane. This prevents cardiac compression. The mediastinal structures are easily visible through the transparent membrane, and rapid access to mediastinal structures can be achieved if necessary. Finally, the wound is isolated from the atmosphere, maintaining an effective barrier to mediastinal contamination. Chest drain suction is kept at a minimum to prevent sucking the silicone membrane onto the heart.

Investigators have demonstrated that hemodynamic compromise after chest closure in children undergoing open heart operations is due to a reduction of ventricular filling as a result of cardiac compression [8, 9]. This phenomenon occurs because of myocardial edema and dilatation of the heart, in association with a rise in pericardial pressure produced by sternal closure. This leads in turn to a fall in transmural left and right ventricular end-diastolic pressures with a concomitant rise in left and right atrial pressures. Echocardiographic studies in adults have proved similarly that the decrease in cardiac output was due to impaired ventricular filling [16]. Keeping the pericardium open reduces the diastolic filling constraints on the left ventricle and consequently improves the cardiac output [17].

The cause of tamponade after open heart operations in children is usually a combination of a big heart, big lungs, big abdomen, bleeding, and clots. One of us (MdL) routinely places a peritoneal drainage catheter in the abdomen at the end of an operation in which the bypass has been prolonged. This catheter is thought to be useful to drain the fluid collecting in the peritoneum, thus improving the right atrial filling pressures and eventually the blood pressure. The catheter also could be used for peritoneal dialysis if needed.

Mechanical restriction of ventricular relaxation can occur in the absence of intrapericardial blood or clot and contribute to low cardiac output [11]. Capillary leak syndrome and an increase in lung water also can contribute to cardiac compromise. Delayed sternal closure successfully prevented the limitation of diastolic filling in the heart imposed by pulmonary problems such as severely congested or overinflated lungs.

Mediastinal infection has been reported to be a possible side effect of delayed sternal closure [18–20], especially in patients in whom the low cardiac output leads to poor tissue perfusion. However, in the current large series, infection has not been an important problem. Sternal instability also has not been a problem in our series.

In conclusion, delayed sternal closure with sternal stenting and silicone membrane skin closure is a safe and helpful procedure in infants and children with compromised cardiac output after repair of complex cardiac defects.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
This research was presented at The Second World Congress on Pediatric Intensive Care, Rotterdam, the Netherlands, June 23–26, 1996.

Address reprint requests to Mr Elliott, Hospital for Sick Children, Great Ormond St, London WCIN 3JH, England.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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2. Mestres CA, Pomar JL, Acosta M, et al. Delayed sternal closure for life-threatening complications in cardiac operations: an update. Ann Thorac Surg 1991;51:773–6.[Abstract/Free Full Text]
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14. Hakimi M, Walters HL, Pinsty WW, Gallagher MS, Lyons JM. Delayed sternal closure after neonatal cardiac operation. J Thorac Cardiovasc Surg 1994;107:925–33.[Abstract/Free Full Text]
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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): Jeffrey P. Jacobs Marc R. de Leval Jaroslav Stark Martin J. Elliott Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iyer, R. S. Articles by Elliott, M. J. Search for Related Content PubMed PubMed Citation Articles by Iyer, R. S. Articles by Elliott, M. J.