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Ann Thorac Surg 2003;75:638-639
© 2003 The Society of Thoracic Surgeons

Correspondence

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

Farzan Filsoufi, MD, Lishan Aklog, MD, David H. Adams, MD

Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, New York, NY 10029, USA

To the Editor:

We thank Dr Misawa for his comments regarding our article on the liberal use of delayed sternal closure in patients with postcardiotomy hemodynamic instability [1]. As mentioned by Dr Misawa, the study design and the indications for delayed sternal closure are different in these two clinical experiences. However, the principal conclusions are identical, emphasizing the safety of delayed sternal closure with a low incidence of sternal infection as well as improved survival in this very high risk group of patients.

The study by Misawa and colleagues [2] also deserves some comments. His group chose to delay sternal closure if left- or right-sided filling pressures increased during attempted closure. The author did not mention if any other preoperative or intraoperative variables were used to select patients for delayed sternal closure. An increase in filling pressures at the time of chest closure is a common finding, particularly in patients with cardiomegaly, cardiac edema, and right ventricular dilatation. These are not also reliable parameters in the setting of mitral or tricuspid valve regurgitation. Valvular regurgitation is frequent in patients with left/right ventricular failure and severity depends directly on loading conditions. Therefore, filling pressures are unlikely to be sensitive or specific enough to identify those patients who may benefit hemodynamically from delayed sternal closure. This may explain the higher incidence of open chest in Misawa’s series compared with ours (3.5% vs 1.7%). We believe that variables that evaluate systemic perfusion (blood pressure, cardiac index) are more reliable than filling pressures in selecting patients for this approach.

The timing of chest closure was also different in these two reports. In our experience the mean time to sternal closure was 3.7 days (3.2 days in survivors and 6.2 days in nonsurvivors). In Misawa’s cohort, delayed sternal closure was performed successfully in 7 patients at a mean of 6 days. This significant increase in the length of open chest can probably be attributed to the differences in indications on delayed sternal closure as well as criteria and variables used to define the appropriate timing of chest closure.

In conclusion, we would again emphasize that liberal use of open chest management is useful in patients with postcardiotomy shock and can be carried out with a low incidence of sternal infection as demonstrated by Misawa’s and our experience.

References

  1. Anderson C.A., Filsoufi F., Aklog L., et al. 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
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Lishan Aklog
David H. Adams
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Right arrow Articles by Filsoufi, F.
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