Ann Thorac Surg 1998;65:846-847
© 1998 The Society of Thoracic Surgeons
Case Reports
One-Stage Sternal Stenting With Homograft Bone After Cardiac Operation in Pediatric Patients
Jaw-Ji Chu, MD,
Chau-Hsiung Chang, MD,
Pyng Jing Lin, MD,
Wen-Jen Su, MD,
Peter P. C. Tan, MD
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
Department of Pediatric Cardiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
Accepted for publication October 23, 1997.
Dr Chang, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa North Rd, Taipei, Taiwan 105.
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Abstract
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Low cardiac output after open heart operations in neonates and infants carries a high mortality. Delayed sternal closure may be life-saving but may prolong hospital stay and increase costs. To circumvent these issues, we shaped homograft bone and interposed it between the sternal edges to allow primary wound closure in 2 pediatric patients. Midterm results are satisfactory.
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Introduction
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The rate of delayed sternal closure after open heart operations in infants is higher than for older children, with a reported incidence of between 5.6% and 30% [1][2]. A decrease in intrathoracic pressure with an open chest is one mechanism of increasing cardiac output after cardiac repair. This traditional approach may involve meticulous hemostasis of the open mediastinum, a stent to keep the sternal edge apart, an aseptic dressing, a suction and irrigation system with chest tube drainage, prolonged intensive care unit stay, and later secondary or delayed closure of the sternum. Consequently, postoperative care is complex, hospital stay and medical costs increase, and wound infection is a potential hazard.
With the availability of bone homograft, it seems logical to perform one-stage sternal closure without leaving the chest open in such cases. We herein report our experiences in primary chest closure with a homograft bone interposed between the sternal edges in 2 pediatric patients.
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Case Reports
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Patient 1
A 3-year-7-month-old girl was referred to us with D-transposition of the great arteries, ventricular septal defect, atrial septal defect, and infundibular and valvular pulmonary stenosis. She underwent a Rashkind procedure at 1 month of age at the time of diagnosis. She was lost to follow-up until June 1996. Cardiac catheterization confirmed an adequately sized pulmonary arterial tree. A Rastelli operation was performed and a 20-mm Hemashield (Meadox Medicals, Oakland, NJ) woven graft was interposed between the right ventricle and the main pulmonary artery. The hemodynamic status was stable after the discontinuation of cardiopulmonary bypass, but low cardiac output occurred with attempted sternal closure because of right ventricular outflow tract compression.
Homograft bone was chosen as an alternative to delayed sternal closure to avoid a second operation. A fibular homograft was taken from our cryopreserved bone bank, shaped, and interposed between the edges of the sternal wound (Fig 1). Then the chest was closed primarily with partial mobilization of the pectoral fascia and subcutaneous tissue. The hemodynamic condition improved and the patient was sent to the intensive care unit with reduced inotropic requirements. Within 24 hours the patient was weaned from the ventilator. The patient was discharged from the hospital on day 6, asymptomatic, and has remained so at follow-up 9 months later. The sternal wound healed well and remains stable.
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A cryopreserved fibular homograft was shaped, then spaced appropriately and wedged between the edges of the sternotomy. Peristernal wires were placed and soft tissue was closed as in the usual technique with mobilization of pectoral fascia and subcutaneous tissue.
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Patient 2
A 10-day-old baby boy with total anomalous pulmonary venous return (supracardiac type) and a patent ductus arteriosus was referred to us. Cardiac catheterization showed stenosis between the vertical and innominate veins and severe pulmonary hypertension. Surgical repair was performed under hypothermic circulatory arrest. The hemodynamic condition stabilized 30 minutes after weaning from bypass; however, an important drop in blood pressure accompanied each attempt at sternal closure. Thus a cryopreserved radial homograft was shaped and sandwiched between the sternal edges. The chest was then easily closed without hemodynamic compromise. The postoperative course was uneventful except for ventilator dependence for 2 days. The patient was discharged in stable condition and followed up in clinic with satisfactory sternal wound healing at 6 months after the operation.
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Comment
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Leaving the sternal halves apart rather than attempting primary closure after cardiopulmonary bypass is a life-saving measure, particularly when low cardiac output persists despite the use of inotropic agents in neonates and infants [3]. The mechanism of restored hemodynamic stability after opening the sternum is a result of releasing a tamponade-like reduction in ventricular filling that may precipitate cardiogenic shock [4]. Even though open sternotomy provides improved survival for those critically ill pediatric patients, postoperative care is always complex. Prolonged ventilator support with an extended intensive care unit stay and a second operative procedure is unavoidable.
To avoid a second operation and the potentially undesirable complicated postoperative care, a single-stage sternal closure that does not compromise hemodynamically unstable patients after a cardiac operation is an attractive alternative to delayed sternal closure techniques. Sternal upward traction with full-thickness chest wall sutures has been reported with satisfactory results [5]. Even though this procedure avoids the need for secondary sternal closure, the traction device with an orthopedic frame still requires substantial attention. The patients require sedation and anesthesia during the intensive care unit stay, with delays in patient recovery. To avoid external traction devices, another option for primary closure of sternum is inlay autologous rib grafts between the edges of the sternotomy [6][7]. This technique was successfully applied in an adult patient after a heart operation [6]. Autologous rib grafts may not be applicable in patients with coagulation disorders such as cyanotic heart disease. Furthermore, small rib grafts may not be as effective for cardiac decompression in infants and small children with a bulky heart and an extracardiac conduit like our first patient.
Bone graft, either autologous or homologous, is used extensively in orthopedic and plastic procedures for reconstruction of bony defects. This article presents our experience using homograft bone to decompress the hemodymically unstable pediatric patients after cardiac operations. Midterm results confirm adequate initial decompression, simple postoperative care, early weaning from the ventilator, reduced hospital stay and costs, stable bony healing, and growth.
In conclusion, cardiac edema and extracardiac conduits after operation for complex cyanotic heart disease are the major causes of low cardiac output after sternal closure. With reduced priming volume and ultrafiltration techniques [8], the incidence of cardiac compression may decrease but cannot be eliminated. In view of the potential recovery and simple postoperative care, sternal osteoplasty with homograft bone may be a better and easy alternative to delayed sternal closure and autologous rib grafts for pediatric patients.
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References
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- Elami A, Permut LC, Laks H, Drinkwater DC, Jr, Sebastian JL Cardiac decompression after operation for congenital heart disease in infancy. Ann Thorac Surg 1994;58:1392-1396.[Abstract]
- Odim JNK, Tchervenkov CI, Dobell ARC Delayed sternal closure: a lifesaving maneuver after early operation for complex congenital heart disease in the neonate. J Thorac Cardiovasc Surg 1989;98:413-416.[Abstract]
- Shore DF, Capuani A, Lincoln C Atypical tamponade after cardiac operation in infants and children. J Thorac Cardiovasc Surg 1982;83:449-452.[Abstract]
- Ziemer G, Karck M, Muller H, Luhmer I Staged chest closure in pediatric cardiac surgery preventing typical and atypical cardiac tamponade. Eur J Cardiothorac Surg 1992;6:91-95.[Abstract]
- McEnany MT Sternal traction after open heart operation: an effective alternative to delayed sternal closure. Ann Thorac Surg 1995;60:387-391.[Abstract/Free Full Text]
- Geiger JP, Tabak CA, Aronstam EM Primary sternal closure and mediastinal decompression by inlay autologous rib grafts. Ann Thorac Surg 1996;61:215-216.[Abstract/Free Full Text]
- Chiu IS, Huang TS, Chu SH, Hung CR Sternal splintage with rib graft to avoid retrosternal compression after open heart surgery—an experimental study. Int J Cardiol 1984;5:517-521.[Medline]
- Elliott MJ Ultrafiltration and modified ultrafiltration in pediatric open heart operations. Ann Thorac Surg 1993;56:1518-1522.[Abstract]
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Abstract
Introduction
