Ann Thorac Surg 1997;63:572-574
© 1997 The Society of Thoracic Surgeons
How To Do It
Spool-Like Stent for the Open Sternum After Cardiac Operations
Hisashi Satoh, MD,
Kei Sakai, MD,
Masahiro Koyama, MD,
Hikaru Matsuda, MD
Cardiovascular Surgery, Yao Tokushyukai General Hospital, and First Department of Surgery, Osaka University Medical School, Osaka, Japan
Accepted for publication September 24, 1996.
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Abstract
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Severe edematous heart after a cardiac operation is impossible to treat if there is compression of the heart due to the sternum. In these patients delayed sternal closure may be a useful procedure until the heart decreases in size. We devised a spool-like stent for the open sternum to maintain the optimal cardiac space for the severely edematous heart and to fix the chest wall to allow for management while the sternum is open.
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Introduction
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After cardiac operations on severely ill patients, it is sometimes impossible to close the sternum because of severe cardiac edema, uncontrollable mediastinal bleeding, and the multiple perfusion cannulas for mechanical circulatory assist [1–6]. In such cases it is sometimes necessary to leave the sternum open with a stent and to close the sternum after resolution of the edema. We have used stents made from bent metal spatulas and a piece of polyvinyl tube. Using these stents, it was easy to open the sternum. However, it was impossible to fix the sternum, and thus the chest wall was shaky and unstable. We devised a spool-like stent made from polypropylene syringes. This technique was used in 5 patients with severe cardiac edema after cardiac operations and proved to be useful in the management of patients with an open sternum.
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Technique
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The spool-like stents were made from two different-sized polypropylene syringes. One and a half to 2.0 cm of the end of the outer barrel of two plastic syringes were cut and combined so that they resembled a spool (Fig 1
). With a combination of a 50-mL and a 30-mL syringe, the diameter of the center core is 35 mm, with a 30-mL and a 20-mL syringe is it 30 mm, and with a 20-mL and a 10-mL syringe it is 25 mm (Fig 2). These stents were placed on the edge of the open sternum and sutured to the sternum with a heavy suture (Fig 3). We always used a combination of two or three stents to open the sternum by 2 to 5 cm. The skin and subcutaneous tissue were widely elevated from the deep fascia and sutured with a monofilament suture, creating a watertight and airtight closure. In all patients it was possible to close the skin wound without any patch or membrane. Over this was placed a sterile, iodine-impregnated occlusive dressing. Using this technique, the sternum was firmly fixed and it was easy and safe to perform percussion on the chest for respiratory management and to change the body position. After a few days' treatment in the intensive care unit, cardiac function improved sufficiently to achieve sternal closure.
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Fig 1. . Making of the spool-like stent. The ends of the outer barrel of two different-sized polypropylene syringes were cut in a circular fashion.
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Fig 2. . The spool-like sternal stent (left to right: 50 mL and 30 mL, 30 mL and 20 mL, 20 mL and 10 mL).
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This technique was applied to 5 patients for delayed sternal closure. Two of these patients underwent emergency coronary bypass grafting for an acute myocardial infarction with cardiogenic shock. Severe cardiac edema subsequently developed, and sternal closure produced marked severe hypotension and intractable ventricular arrhythmia. The patients could be maintained in stable hemodynamic condition with the sternum open using the sternal retractor. The spool-like stent was used to close the chest wall (Fig 4). Cardiac function improved after treatment with inotropic drugs, diuresis, continuous hemofiltration, and respiratory care in the intensive care unit. Delayed sternal closure was performed on the 8th and 10th postoperative days. After delayed sternal closure, the endotracheal tube was removed. One patient died of intractable ventricular fibrillation on the 21st postoperative day. The other patient survived (Fig 5).
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Fig 5. . (A) Preoperative status in severe cardiogenic shock after acute myocardial infarction. (B) Postoperative status with the spool-like stent technique.
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In the 3 other patients, a ventricular assist system was implanted using a centrifugal pump for postcardiotomy shock during cardiac operations. One patient had ventricular septal perforation after acute myocardial infarction. This patient had biventricular failure after operation, so biventricular assist using a centrifugal pump was applied. Two patients had profound left heart failure after elective heart operations; in them, applied left ventricular assistance was applied using a centrifugal pump. The sternum could not be closed due to multiple direct cannulation for assist circulation and chest tubes, so the spool-like stent was used and the chest wall was closed without a membrane. After weaning from the mechanical ventricular assist, the sternum was closed immediately or after a few days. One of the 3 patients survived. No mediastinitis or major wound complications developed in any patient in whom this technique was used.
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Comment
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Delayed sternal closure after cardiac operation is a useful procedure to rescue severely ill patients who have severe hypotension and intractable arrhythmias from the primary sternal closure, intractable mediastinal bleeding, and the presence of mediastinal mechanical circulatory assist [1–6]. A decrease in heart size may occur during the early postoperative period as cardiac function improves, and the sternotomy may be closed within a few days. It was difficult to close the chest wound without a membrane by the conventional stent technique in our patients. Mediastinal infection is the most critical problem in these patients. We experienced no mediastinitis or major wound complications using this delayed sternal closure technique. In the procedure without stents the edge of the sternum may compress the heart and the chest wall can be unstable and shaky. It is difficult to care for severely ill patients with an unfixed chest wall during early postoperative management [7].
We believe that the small sternal opening of 2 to 5 cm provides adequate substernal space for the edematous failing heart. The fixed and stable chest wall provides easy transport, nursing, and any other postoperative management of these severely ill patients.
This technique provides a sterile covering due to skin closure without any patch or membranes, and the remarkably stable sternum allows adequate respiratory management. These spool-like stents are easy to apply and make with the usual medical sterilized instruments. We believe this technique may be useful in the clinical management of cardiac surgical patients in whom sternal closure is precluded by accidental myocardial edema.
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Footnotes
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Address reprint requests to Dr Satoh, Cardiovascular Surgery, Yao Tokushyukai General Hospital, 3-15-38 Kyuhoji, Yao, Osaka 581, Japan.
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References
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- Fanning WJ, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg 1987;44:169–72.[Abstract/Free Full Text]
- Josa M, Khuri SK, Braunwald NS, et al. Delayed sternal closure. J Thorac Cardiovasc Surg 1986;91:598–603.[Abstract]
- Ganghar DM, McCough EC, Synhost D. Secondary sternal closure: a method of preventing cardiac compression. Ann Thorac Surg 1981;31:281–2.[Abstract/Free Full Text]
- Gielchinsky I, Parsonnet V, Krishnan B, Silidker M, Abel R. Delayed sternal closure following open-heart operation. Ann Thorac Surg 1981;32:273–7.[Abstract/Free Full Text]
- Jones SD, Fullerton DA, Campbell DN, et al. Technique to stent the open sternum after cardiac operations. Ann Thorac Surg 1994;58:1186–7.
- Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operation. Ann Thorac Surg 1992;54:233–9.[Abstract/Free Full Text]
- Majid AA. Plastic struts for delayed sternal closure [Letter]. Ann Thorac Surg 1990;50:1021.
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Abstract
Introduction
