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a Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
b Department of Biostatistics, Emory University, Atlanta, Georgia
c Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
d Medical College of Georgia, Augusta, Georgia
Accepted for publication March 31, 2009.
* Address correspondence to Dr Kirshbom, 1405 Clifton Rd, Pediatric Cardiothoracic Surgery, Atlanta, GA 30322 (Email: paul.kirshbom{at}emoryhealthcare.org).
Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract |
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Methods: Eight hundred two patients with congenital heart disease had 1,000 consecutive repeat sternotomies between August 2000 and November 2007. Records were reviewed for demographics, history, operative techniques, and outcomes. Univariate risk factors for reentry injury and operative mortality were assessed.
Results: Median age and weight were 2.1 years (range, 0.1 to 34.6 years) and 11 kg (range, 2.5 to 123 kg). There were 639 second, 287 third, and 74 fourth or higher sternotomies. There were 13 reentry injuries (1.3%) involving right ventricle–pulmonary artery conduits (n = 4), aorta or aortic conduits (n = 3), right ventricular outflow tract patches or pseudoaneurysms (n = 3), and others (n = 3). Risk factors for injury were presence of a right ventricle–pulmonary artery conduit (6 of 115 with conduit [5.2%] versus 7 of 885 without [0.8%]; p < 0.001) and sternotomy number (relative risk, 2.28; p < 0.001). Reentry injury was associated with longer procedure times (median, 420 minutes with injury versus 248 without; p < 0.001). Operative mortality occurred in 18 patients and was associated with sternotomy number and procedure time (p < 0.001), but not reentry injury (p = 0.2).
Conclusions: Risk of reentry injury during repeat sternotomy for congenital heart disease is low. Increasing sternotomy number and the presence of a right ventricle–pulmonary artery conduit are risk factors for reentry injury. However, reentry injury is not associated with increased risk of operative mortality.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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DeLeon and colleagues [1] and Russell and associates [2] have previously reported a 5% risk of injury to the heart or vascular structures during sternal reentry for procedures performed during the 1980s and 1990s. However, a recent report by Morales and colleagues [3] suggests that the risk of reentry injury is less than 1% and is not significantly different from primary sternotomy.
The goals of this study were to determine the incidence of reentry injury during repeat sternotomy and identify risk factors, if any. We also sought to determine the impact of reentry injury on morbidity and perioperative mortality.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Operative Techniques
The standard technique used for repeat sternotomy during this period was dissection of the retrosternal space beginning at the xiphoid process with anterior retraction of the sternal leaves. The sternum was typically opened sequentially as the retrosternal space was dissected using an oscillating saw to open the anterior table and scissors or electrocautery for the posterior table. Elective femoral vessel exposure or cannulation was performed at the discretion of the surgeon.
Reentry Injury
Reentry injury was defined as an injury to cardiac or vascular structures during the sternotomy or during the dissection before cannulation for cardiopulmonary bypass. Using the definition of Morales and coworkers [3] a major injury was defined as an injury resulting in nonelective peripheral cannulation for cardiopulmonary bypass, blood transfusion, or initiation of inotropic drug treatment during management of the injury, or postoperative morbidity attributable to the injury. Minor injuries were controlled without peripheral cannulation, transfusion, hypotension, or inotropic agents and resulted in no evident morbidity.
Statistical Methods
Data are reported as medians (ranges). Fisher's exact or Wilcoxon rank-sum test was performed to assess risk factors for reentry injury and perioperative mortality as appropriate. Multivariate analysis was not possible because of insufficient end points. A probability value of less than 0.05 was considered statistically significant.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Univariate analysis revealed a significant association between reentry injury and the presence of a right ventricle–pulmonary artery conduit (injury in 6 of 115 [5.2%] with conduit versus 7 of 885 [0.8%] without; p = 0.002) and sternotomy number (Table 2; p < 0.001). Reentry injury was also associated with longer total procedure times (p = 0.008).
Because of the surgeons' perception of the risk of sternal reentry, the femoral vessels were electively exposed before sternotomy in 10 patients. Three of these patients were electively cannulated using the femoral vessels before initiation of the sternotomy. Of these 10 patients, 1 experienced a minor injury with rupture of a right ventricle–pulmonary artery pseudoaneurysm that was controlled with digital pressure while standard aortic and right atrial cannulations were performed. Four patients underwent emergent femoral cannulation after reentry injury occurred, so a total of 7 patients were placed on peripheral cardiopulmonary bypass (3 elective, 4 emergent).
Twenty patients had a polytetrafluoroethylene membrane present beneath the sternum at the time of re-sternotomy. The presence of a polytetrafluoroethylene membrane was associated with an increased likelihood of reentry injury with 3 of 20 (15%) injuries with a membrane as opposed to 10 of 980 (1%) without (p < 0.0001). These data are confounded by the selection bias inherent in the decision to place a substernal membrane at our institution. For example, 13 of 20 patients (65%) with membranes had right ventricle–pulmonary artery conduits as opposed to only 102 of 980 patients (10%) who did not have a substernal membrane.
Operative Mortality and Perioperative Morbidity
Operative mortality, defined as patient death before hospital discharge or within 30 days of surgery, occurred after 18 of 1,000 repeat sternotomy procedures (1.8%). Mortality was found to be associated with sternotomy number (Table 2; p < 0.001) and procedure time (p < 0.001). Mortality was not significantly associated with the occurrence of reentry injury (mortality in 1 of 13 patients [7.7%] with reentry injury versus 17 of 987 [1.7%] without injury; p = 0.2).
Assignment of postoperative morbidity to reentry injury is difficult, as many of these patients underwent prolonged procedures that are associated with potential morbidity with or without reentry injury. For example, 1 patient who had an aortic injury upon sternal reentry experienced dialysis-dependent postoperative renal failure; however, that patient had preoperative renal insufficiency and had no hypotension associated with the injury, so the role of the reentry injury is difficult to determine There were also 2 patients with postoperative neurologic impairment after an operation complicated by reentry injury. One had a major stroke documented before the operation, so the postoperative impairment cannot be attributed to the reentry injury alone. The other child was born with hypoplastic left heart syndrome and sickle cell anemia, had undergone staged palliation, followed by Fontan failure, heart transplantation, and eventual graft failure. He then experienced an innominate vein injury during reentry for his redo transplant. Although he did not have a cardiac arrest, there was concern about possible micro–air embolization. The evaluation of his postoperative encephalopathy demonstrated chronic and acute watershed infarcts. Again, it is difficult to differentiate the relative roles of the reentry injury as opposed to sickle-cell anemia and chronic illness in the generation of his postoperative encephalopathy, but it certainly may have contributed.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Although neither we nor the Texas Children's Hospital group [3] perform routine radiologic studies to assess the risk of repeat sternotomy in all patients, it seems clear that most if not all experienced surgeons recognize that some repeat sternotomy patients are at higher risk than others. Our findings were somewhat different from the findings of Morales and coworkers [3] in that we did identify the presence of a conduit and sternotomy number as significant risk factors for reentry injury. Our data support the commonly held belief that there are repeat sternotomy patients who are at increased risk for reentry injury relative to both primary sternotomy patients and other, lower-risk resternotomy patients. With this information in hand preoperatively, the surgeon can consider all options that he or she believes might be warranted to mitigate this risk.
These data may allow for tailored use of previously described or new techniques designed to decrease the risk of reentry injury. Placement of a substernal membrane made of either expanded polytetrafluoroethylene or newer materials or selective femoral vessel cannulation for peripheral cardiopulmonary bypass has been discussed in the literature. Although our institution and many others have not adopted the routine use of substernal polytetrafluoroethylene membranes, Jacobs and collaborators [4] did publish a relatively small study involving 105 repeat sternotomies after placement of such membranes in 1,085 patients with 1 injury (1%) during reentry. It is interesting to note that the presence of a substernal membrane was associated with a higher incidence of reentry injury in our patient cohort. However, substernal membranes were used selectively and rarely (20 of 1,000, 2%), so this may well be the result of an inherent selection bias. As mentioned above, patients who had a membrane placed were much more likely to have a right ventricle–pulmonary artery conduit than were those without. Because of the small number of end points, we did not have sufficient statistical power to conduct a multivariable regression analysis, so the question of confounding variables cannot be answered with this data set.
It was also somewhat difficult to determine the effectiveness of elective femoral vessel exposure in this cohort. Three patients were electively placed on peripheral cardiopulmonary bypass before initiation of sternotomy, and these 3 patients did not experience a reentry injury. However, of the remaining 7 patients whose femoral vessels were exposed, only 1 experienced an injury, and this patient was safely cannulated through the chest. Therefore, none of these 7 patients benefited from femoral vessel exposure. Meanwhile, the 4 patients who did require emergent femoral cannulation did not have their femoral vessels preemptively exposed. Therefore, the sensitivity and specificity with which elective femoral vessel exposure was used in this series was quite low.
Finally, the results of this study agree with previous adult and pediatric reports [3, 5] in that reentry injury does not significantly increase the risk of operative mortality. Therefore, we agree that the risk of repeat sternotomy should not be the primary determining factor when deciding on a treatment algorithm for a particular patient. However, there are clear risk factors that increase the risk for certain patients, and we contend these risk factors should not be discounted out of hand. Appropriate consideration of each patient, taking the likelihood of subsequent reentry injury into account, may allow surgeons to continue to improve outcomes for our more complicated patients.
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