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Ann Thorac Surg 2003;75:638
© 2003 The Society of Thoracic Surgeons

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Correspondence

Liberal use of delayed sternal closure: sternal infection does not increase

Division of Cardiovascular Surgery, Jichi Medical School, 3311-1 Yakushiji, Minami-kawachi, Tochigi 329-0498, Japan

e-mail: tcvmisa{at}jichi.ac.jp

To the Editor:

I read with great interest the article by Anderson and associates [1]. The authors mentioned that liberal use of delayed sternal closure was useful in patients with postcardiotomy shock with a relatively low incidence of sternal complications.

We reported a prospective study of delayed sternal closure after cardiac operation in a cohort of 201 consecutive patients between 1989 and 1991 [2]. Delayed sternal closure was scheduled when mean left atrial or central venous pressure increases persisted at 2 mm Hg or more above the initial level during trial sternal closure. Patients with bleeding or who required transthoracic mechanical circulatory assist were excluded in our study. Among 201 patients, 7 patients (3.5%), whose mean age was 50 ± 6 years, required delayed sternal closure. Mediastinal isolation was accomplished by direct skin suture in 6 patients and by using a polytetrafluoroethylene membrane between the skin edges in 1 patient. Antibiotic prophylactic administration of both flomoxef sodium and fosfomycin was maintained to or beyond sternal closure. The 7 patients successfully underwent sternal closure 6 ± 3 days after the initial operation without any difficulties. The irrigation protocol consisted of 0.51.0 L of normal saline with or without povidone iodine. Postoperative microbiological examination of the mediastinal and pericardial contents obtained before the irrigation at the sternal closure revealed negative organism growing in all patients, and no patient developed sternal complications such as infection. Sternal reopening was not required thereafter, and all the patients were hemodynamically stable after the closure.

Our study consisted of a small number of patients between 1989 and 1991 and the study by Anderson and associates [1] received a large number of patients (5,177) between 1997 and 2000. Ours study was prospective and Anderson and associates’ [1] study was retrospective. Thus some differences in patient background may exist between the two studies. However, each study showed that delayed sternal closure can be a safe and effective strategy for postcardiotomy hemodynamic instability. Although some cardiac surgeons may be afraid of possible infectious complications of the sternum after delayed sternal closure, delayed sternal closure should be liberally used to stabilize hemodynamic conditions during wound closure.

References

1. Anderson C.A., Filsoufi F., Aklog L., Farivar R.S., Byrne J.G., Adams D.H. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. Ann Thorac Surg 2002;73:1484-1488.[Abstract/Free Full Text]
2. Misawa Y., Hasegawa T., Fukushima K., et al. Delayed sternal closure after cardiac surgery. Nippon Kyobu Geka Gakkai Zasshi 1992;40:1085-1088.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshio Misawa Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Misawa, Y. Search for Related Content PubMed Articles by Misawa, Y. Related Collections Cardiac - other