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Ann Thorac Surg 1997;64:1519-1520
© 1997 The Society of Thoracic Surgeons

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Correspondence

Sternal Stent for Delayed Closure

University Hospital Antwerp, Department of Cardiac Surgery, 2560 Edegem, Belgium

To the Editor:

We read with great interest the How to Do It article on delayed sternal closure by Satoh and associates [1]. We reported our results at the 45th Congress of the European Society for Cardio-Vascular Surgery in September 1996 in Italy [2].

Instead of using stents as reported by Satoh and associates, we used compression plates from the orthopedic surgeons. The plate is simply sutured by steel wire to the sternal edges through one of its holes. We think that leaving the sternum only 2 to 5 cm open is an absolute minimum. With the use of compression plates any distance can be obtained. The technique also offers stable fixation, enabling the patient to be mobilized. We reported on 9 patients or 0.4% of our adult patients operated on between January 1993 and January 1996. Patients on ventricular assist devices were excluded. There were 5 male patients with a mean age of 65 years and 4 female patients with a mean age of 71 years. Hemodynamic instability was caused by attempted sternal closure in 6 patients, bleeding with tamponade in 2 patients, and severe pulmonary emphysema without noncardiogenic pulmonary edema causing cardiac compression in 1 patient.

In 6 patients the sternum was eventually closed, and 3 patients survived and are currently in New York Heart Association class I. The remaining patients died of sepsis and multiorgan failure. As in the report by Satoh and associates, all deep and superficial wound cultures were sterile.

References

1. Satoh H, Sakai K, Koyama M, Matsuda H. Spool-like stent for the open sternum after cardiac operations. Ann Thorac Surg 1997;63:572–4.[Abstract/Free Full Text]
2. Haenen L, Rodrigus I, Boeckxstaens C, Amsel BJ, Moulijn AC. Open sternotomy and delayed sternal closure in adult cardiac surgery. Cardiovascular Surgery 1996;4(Suppl 1):166.

Reply

Cardiovascular Surgery, Yao Tokushyukai General Hospital, 3-15-38 Kyuhoji, Yao, Osaka 581, Japan
Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565, Japan

To the Editor:

We thank Dr Haenen and colleagues for their interest in our recent article concerning delayed sternal closure using a spool-like stent [1]. We think their idea using orthopedic compression plates is good and useful too [2]. Before the initiation of our spool-like stenting, we used the chest tube and a metal spreader to keep the sternum open. The sternal opening was wider and all patients required a wide patch for closure of the chest wound.

Mediastinal infection is a life-threatening complication after cardiac operations. The risk of deep mediastinal infection is very high while the sternum is open [3, 4]. We think that primary skin closure without any patch protects the mediastinum from bacterial infection while the sternum is open. Our spool-like stent technique was able to open the sternum only 2 to 5 cm; however, the skin wound was primarily and completely closed without any patch or membrane in all patients. The slightly open sternum with a width of only 2 to 5 cm provides an adequate substernal space for the edematous failing heart under the intensive care with maximal intropic support and mechanically assisted circulation. A widely open sternum maintains a wide pericardial space for the edematous failing heart, but it is not possible to primarily close the chest wound without any patch procedure. A patch procedure would cause a high risk of mediastinal infection. A fixed and stable chest wall provides easy postoperative management of severely ill patients while the sternum is open. Our spool-like stents are easy to apply and make with the usual sterilized instruments in any accidental situation, and these stents are very inexpensive.

References

1. Satoh H, Sakai K, Koyama M, Matsuda H. Spool-like stent for the open sternum after cardiac operations. Ann Thorac Surg 1997;63:572–4.[Abstract/Free Full Text]
2. Haenen L, Rodrigus I, Boeckxstaens C, Amsel BJ, Moulijn AC. Open sternotomy and delayed sternal closure in adult cardiac surgery. Cardiovascular Surgery 1996;4(Suppl 1):166.
3. Mestres CA, Pomar JL, Acosta M, et al. Delayed sternal closure for life threatening complication in cardiac operation. Ann Thorac Surg 1991;51:773–6.[Abstract/Free Full Text]
4. Fanning WJ, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg 1987;44:169–72.[Abstract/Free Full Text]

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