Ann Thorac Surg 2005;80:684-685
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Martin Kostelka, MD, PhD
Department of Cardiac Surgery, University Leipzig, Strumpellstrasse 39, Leipzig, Germany 04289
(Email: kostelm{at}medizin.uni-leipzig.de).
As the authors pointed out, 5 major reasons can be identified for leaving the sternum open: bleeding, dysrhythmia, myocardial edema, myocardial dysfunction and the necessity for mechanical ventricular support.
It is well understood that the capillary leak syndrome developing in the early postoperative course will aggravate myocardial edema and myocardial dysfunction. Since capillary leak syndrome is worst on postoperative days 1 to 3, the sternum should not be closed at that time for most indications; however, bleeding may be an exception. In other clinical reports the sternum was left open electively (prophylactically) to avoid postoperative cardiac or respiratory compromise in addition to other medical reasons. Some have tried to define indications for delayed sternal closure (DSC) on the basis of hemodynamics. Samir and colleagues [1] identified several clinical factors in newborns associated with the need for DSC, including diagnosis of IAA or TAPVD; age less than 7 days; aortic clamping more than 98 min; CPB time more than 185 minutes; and a post-bypass venous saturation less than 51%. It is obvious that sternal closure can normally be achieved earlier in patients with prophylactic indication than in patients with cardiac complications. Therefore early DSC would be preferred for patients with elective indication for DSC. These authors report no patient with prophylactic DSC. The results, however, are even more surprising in 18 patients who required emergency resternotomy in the intensive care unit. The authors did not find any significant alterations in heart rate, blood pressure, central venous pressure, LA pressure, oxygenation index, arterial pH nor increase of inotropic support during a 6-hour period after DSC. This is in wide contrast to almost all other reports.
The authors address the issue regarding the high proportion of patients for whom the primary indication was hemostasis. This is the focus of an ongoing study in their institution. However, it is obvious that bleeding complications and coagulation disorders can usually be managed within the first few postoperative hours to allow early delayed sternal closure.
Forty nine of 66 patients (74.2%) had bleeding/tamponade as the indication for DSC. It is questionable to make general statements regarding other indications founded on only 17 remaining patients. The value of this study could be improved by focusing on postsurgery low cardiac output patients.
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- Samir K, Riberi A, Ghez O, Ali M, Metras D, Kreitmann B. Delayed sternal closurea life-saving measure in neonatal open heart surgery; could it be predictable?. Eur J Cardiothorac Surg 2002;21:787-793.[Abstract/Free Full Text]
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