Delayed sternal closure: an effective procedure for life-saving in open-heart surgery/Acik kalp cerrahisinde hayat kurtarmada etkili bir islem: Sternumun gec kapatilmasi.
Delayed sternal closure: an effective procedure for life-saving in open-heart surgery
Objective: To determine the incidence, short term survival and safety of delayed sternal closure following open-heart operation due to myocardial edema, non-surgical bleeding and malignant arrhythmia.
Methods: We retrospectively reviewed our medical records to identify the patients who underwent delayed sternal closure following open-heart operation and recorded morbidity, mortality postoperative complications of these patients. Among 2698 patients who underwent on-pump cardiac surgery, the sternum was left open in 46 (1.7%) patients, 31 men and 15 women, ranging in age from 2 to 73 years (mean 57.0+7.6 years). In 39 patients sternum was left opened following the initial operation and in 7 patients sternum was re-opened due to bleeding or hemodynamic instability after initial surgery. Statistical analysis was accomplished using Chi-square test, Mann Whitney U test and analysis of variances for repeated measurements.
Results: The operative procedures were classified as elective in 24 (52.8%), emergency in 10 (22%), urgent in 7 (15.4%), and redo cardiac operations in 5 patients (11%). Bleeding (n=21), hemodynamic instability (n=16), arrest (n=5), and arrhythmia (n=4) were the reasons of delayed sternal closure. The patients had an open sternum for 3.48 [+ or -] 0.35 days. Time to discharge was 21.5 [+ or -] 1.6 days after operation and 17.6 [+ or -] 1.6 days after sternal closure. Mortality within 30 days was 23.9% (7 patients died before closure and the remaining 4 after closure). Complications were mediastinitis (n=2), minor wound infection (n=3) and renal failure (n=5).
Conclusion: Delayed sternal closure is a safe and simple method for treating bleeding, arrhythmia and myocardial edema following on pump cardiac surgery. It is anticipated that as cardiac surgeons become more familiar with the technique of delayed sternal closure, the frequency of its use following on pump cardiac surgery may increase.
Key words: Sternum, on-pump cardiac surgery, delayed closure, cardiac surgery procedures
Acik kalp cerrahisinde hayat kurtarmada etkili bir islem: Sternumun gec kapatilmasi
Amac: Acik kalp cerrahisinden sonra gelisen miyokardiyal odem, cerrahi olmayan kanama, kardiyak arest ve malign aritmili hastalarda, sternumun acik birakilmasinin guvenli ve efektif olup olmadigini arasstirmakti.
Yontemler: Acik kalp cerrahisi uygulanan ve sternumu acik birakilan olgular retrospektif olarak arastirildi. Mortalite, morbidite ve postoperatif komplikasyonlari incelendi. Toplam 2698 hasta acik kalp cerrahisi ile ameliyata alindi. Bunlarin arasinda 46 (%1.7) hastanin sternumu acik birakildi. Hastalann 31'i erkek, 15 kadin idi. Yas araligi 2-73 (ortalama 57.0 [+ or -] 7.6 yil) yil idi. Hastalarin 39'unda cerrahiden sonra sternum kapatilmadan acik birakildi. Yedi hastada ise kanama, hemodinamik bozukluk nedeni ile revizyona alinan hastalar idi. Istatistiksel analizde Ki-kare testi, Mann Whitney U testi ve tekrarlayan olcumler icin ANOVA testi kullanildi.
Bulgular: Ameliyata alman hastalarm 24'u elektif, 10'nu erken, 7 acil cerrahi ayrica, 5'ide redo vakalardan olusuyordu. Yirmi bir olguda kanama, 16 olguda hemodinamik bozukluk, 5 olguda kardiyak arest, 4 olguda da malign aritmi nedeni ile sternum acik birakildi. Ortalama 3.84 [+ or -] 0.35 gun icinde sternum kapatildi. Operasyondan 21.5 [+ or -] 1.6 gun, sternum kapatilmasindan 17.6 [+ or -] 1.6 gun sonra hastalar taburcu edildiler. Otuz gunluk hastane ici mortalite 11 hasta da gelisti (%23.9). Yedi olgu sternum kapatilmadan once, 4 hastada ise sternum kapatildiktan sonra gelisti. Iki hasta da mediastinit, 3 hastada minor yara enfeksiyonlari ve 5 hastada akut bobrek yetmezligi gelisti.
Sonuc: Acik kalp cerrahisinden sonra gelifen miyokardiyal odem, cerrahi olmayan kanama, kardiyak arest ve malign aritmilerde sternumun acik birakilmasi basit ve guvenilir bir teknik olarak gozukmektedir. Acik kalp cerrahisinden sonra bu teknigin kullamm sikliginin artmasinin uygun olacagmi duzunuyoruz.
Anahtar kelimeler: Sternum, on-pump kardiyak cerrahi, gecikmic kapatma, kardiyak cerrahi isjemleri
The concept of the delayed sternal closure (DSC) after adult cardiac surgery was described in 1975 when Riahi and associates reported the use of external traction of the sternum to minimize postoperative tamponade conditions (1,2). Myocardial edema, poor hemodynamic indices, primary pulmonary problems, arrhythmias, unsatisfactory hemostasis and cardiac assist devices may prevent primary sternal closure after open-heart operations (3). Sternal closure in these situations may cause additional myocardial compression. Compression of the heart by its surrounding structures can limit the end-diastolic volume of the ventricles and in turn lead to decrease in cardiac output (4).
Since the initial description, DSC has become a valuable tool in the management of patients with postcardiotomy instability and mediastinal edema with a current incidence (5).
Here we report our experience of 46 patients with simple technique of the DSC following open-heart operations over a period of 7 years with the aim of identifying the risks and assessing the outcomes of this technique.
Overall, 2698 patients underwent open-heart surgery at our hospital between March 2001 and January 2009. We retrospectively reviewed our medical records to identify the patients who underwent DSC following open-heart operation and recorded morbidity, mortality postoperative complications of these patients. The sternum was left open in 46 (1.7%) patients, 31 men and 15 women, ranging in age from 2 to 73 years (mean-57.0 [+ or -] 7.6 years). In 39 patients sternum was left opened following the initial operation and in 7 patients sternum was re-opened due to bleeding or hemodynamic instability after initial surgery. Indications for DSC are given in Table 1. The operative procedure were classified as elective in 24 (52.8%), emergency in 10 (22%), urgent in 7 (15.4%), redo cardiac operations in 5 patients (11%). The primary operative procedures and intraoperative variables are summarized in Tables 2 and 3. Mild ventricular dysfunction was present with a mean ejection fraction of 45.3 [+ or -] 15.2% an average mean pulmonary artery (PA) pressure of 45.0 [+ or -] 25.5 mmHg (n=37).
Standard anesthesia, cardiopulmonary bypass and surgical techniques were employed. For myocardial protection, we preferred blood cardioplegia with normothermia and antegrade-retrograde cardioplegia. All patients received prophylactic antibiotics with combination of cephalosporin and aminoglycosides at induction of anesthesia and thereafter for one week postoperatively. Intraaortic balloon pump (IABP) insertion, preload and after load optimization were the methods to stabilize the patients. IABP were inserted in 20 patients (44%), those who did not have bleeding.
DSC was carried out due to hemodynamic instability, major bleeding, cardiopulmonary arrest and uncontrolled arrhythmia. Major bleeding was defined as bleeding >150cc/hour with an unidentified surgical origin site of bleeding. Major bleeding was the reason of DSC in 13 patients because of difficult or unsatisfactory hemostasis, combined with a risk of tamponade if the sternum were closed primarily. The reason of the bleeding was aortic dissection or aneurysm in 7 patients (54%).
During prolonged sternotomy, the skin was closed by heavy merselin stitches and covered with sterile dressing. The dressing was changed daily using a strictly sterile technique with povidone-iodine. The timing of sternal closure was determined by the level of pharmacological support, correction of coagulation defects, improved hemodynamic parameters, especially when starting weaning from the intra-aortic balloon pump and response to temporary re-approximation of the sternum as a test before deciding to close it. Sternal closure was routinely performed in the operation room. Debridement of all nonviable tissue and meticulous cleaning with serum physiologic solution and then Betadine solution were performed. Multiple bacterial cultures were taken from the chest wound. Two mediastinal as well as the pleural drains were kept in place when necessary. The sternum was rewired before closure of subcutaneous tissue and skin.
Statistical analysis was done with SPSS 10.0 statistical software program (SPSS Inc, Chicago, IL). Statistical analysis was performed using analysis of variances for repeated measurements, Mann Whitney U test for continuous variables and Chisquare test for nominal variables, respectively. Significance of differences was defined as a p value less than 0.05.
The 46 patients who underwent DSC after cardiac operations from March 2001 through January 2009 represent 1.7% of all cases in which cardiac surgery.
Hemodynamic data and inotropic agents
Hemodynamic data are shown in Table 4. Both the central venous pressure and the mean PA pressure decreased from the time of operation to the period before chest closure consistent with fluid mobilization (p<0.05). The cardiac index changed in an inverse fashion to the filling pressures; however, these changes were not significant.
The patients had an open sternum for 3.48 [+ or -] 0.35 days; with a range of 1 to 33 days. Eight patients (17.6%) were extubated within 24 hours of sternal closure. The overall duration of ventilation was 6.2 [+ or -] 0.9 days (range, 2 to 102 days) after sternal closure. Time to discharge was 21.5 [+ or -] 1.6 days after operation and 17.6+1.6 days after sternal closure.
Our operative mortality for DSC patients, defined as death within 30 days or during the same hospitalization, was 27% (n=12). Of the 12 non-survivors, 7 patients died before closure and the remaining 5 after closure. Causes of death were multisystem organ failure (n=4), low cardiac output (n=3), cardiac arrest (n=3), stroke (n=1), and sepsis (n=1). Mortality within 30 days in patients those who did not require DSC was 3.6%.
Two patients (4.4%) required re-exploration for mediastinitis. Methicillin-resistant Staphylococcus aureus was detected in blood samples and mediastinal fluid samples of first patient and he died due to sepsis 27 days postoperatively. The sternum of second patient with mediastinitis was not closed by wiring and left to secondary heeling. This patient recovered from mediastinitis was referred to plastic surgery 3 months postoperatively. Three patients (6.6%) had minor subcutaneous wound infections after closure. These were treated with antibiotics and debridement was performed. Seven patients (15.4%) required tracheotomy before being weaned off the ventilator. Extracorporeal membrane oxygenation was performed in 6 patients (13.2%). Two of the 6 patients requiring extra corporal membrane oxygenation died 2 and 3 days postoperatively. Five patients (11%) had developed renal failure. Three of the five patients developed chronic renal failure and required hemodialysis.
Pulmonary problems occurred in 7 (15.4%) of the patients and included suboptimal ventilation requiring high inflation pressures (n=4), atelectasis (n=3) and intrapulmonary hemorrhage (n=1).
Our study demonstrated that operative mortality for 46 DSC patients, defined as death within 30 days or during the same hospitalization, was 27%. Of the 12 non-survivors, 7 patients died before closure and the remaining 5 after closure in this study. Causes of death were multisystem organ failure, low cardiac output, cardiac arrest, stroke and sepsis. Mortality within 30 days in patients those who did not require DSC was 3.6%.
Recently several reports have appeared in the literature describing prolonged open chest and subsequent DSC as a life saving procedure in patients with uncontrollable hemorrhage, myocardial edema, low cardiac output and arrhythmias postoperatively (3).
Various methods of DSC have been used, including maintaining the sternum open with a self-retaining retractor (6), mediastinal packing (7), Steridrape (3M Health Care, StPaul, MN) film coverage (8), silicone membrane (9) and primary skin closure (10,11). Closure of the skin alone using silicone elastomer sheeting also has proved useful in neonates (9). Gielchinsky et al. (4) reported the first series of 29 adult patients with DSC in 1981. In the same year, Gangahar et al reported relief of tamponade conditions after postoperative sternal reopening in an infant (12,13).
Mechanical restriction of ventricular relaxation can occur in the absence of intrapericardial blood or clot and contribute to low cardiac output (1). Capillary leak syndrome and an increase in lung water also can contribute to cardiac compromise. DSC can prevent the limitation of diastolic filling in the heart imposed by pulmonary problems such as severely congested or overinflated lungs (14-16). We preferred to leave sternum open in patients with bleeding due to high risk of tamponade and the results were satisfactory in these patients. DSC is an effective method to prevent tamponade in such patients.
Large series in adult patients have reported the incidence of wound infection after heart operations at 1.5-1.8 % (17-19). The choice and duration of antibiotic prophylaxis may influence the risk for surgical site infection in patients with DSC. Pollock et al. (20) used gentamycine until sternums were closed with mediastinitis developing in 10.3% (3/29). Another series used triple antibiotic coverage with cefotaxime, piperacilline and teicoplanin (glycopeptide) until 3 days after sternal closure and reported a 0.9% (1/113) incidence of mediastinitis (21,22). Hakimi et al. (23) used a first-generation cephalosporin until sternal closure followed by penicillinase-resistant and an aminoglycoside and reported no cases (0/55). We used cephazolin (50 to 75 mg/kg per day) or vancomycin (40 to 60 mg (kg per day) and gentamycine (5 to 7.5 mg/kg per day) until sternal closure with additional coverage if culture-positive infection developed at other sites. We observed mediastinitis in 2 (4.4%) and minor wound infection in 3 patients (6.6%). Our results confirm the prior studies that report low infection rates in patients with DSC.
We did not closed sternum by wiring in a patient with mediastinitis and left him to secondary heeling. There is little data about secondary heeling for mediastinitis following cardiac surgery. Trouillet et al. (24) reported 19 critically ill adults with acute mediastinitis after cardiac surgery who were treated with granulated sugar, either directly (11 patients) or after failure of continuous irrigation (8 patients). Although 5 of 19 (26%) patients died before discharge, none was because of wound complications. After initial debridement of the wound; 11 underwent secondary surgical closure of the wound and in 3 the wound healed by granulation tissue formation alone. No recurrence of sternal infection has occurred after a mean follow-up of 8.2 months (range 3 to 17). In our patient secondary heeling was effective and he was still alive 2 years postoperatively. However, more reports are needed to demonstrate the efficacy of secondary heeling for mediastinitis in patients sternum left open.
Patients who required DSC had a higher mortality rate than the patients not requiring the procedure (p<0.05). Patients who required DSC constituted a higher risk group than the patients not requiring DSC. They had more urgent or emergent operation procedures, more severe bleeding and increased frequency of renal failure and pulmonary failure.
DSC rate was higher among patients who underwent complex cardiac surgery in our study. Its rate was higher in patients who underwent surgery due to post myocardial infarction, ventricular septal rupture and aortic dissection, redo or combined cardiac surgery (p<0.5). Mortality rates in our patients were similar to previously reported (5, 7, 21, 22).
The aim of the study was to demonstrate DSC effects of low cardiac output, bleeding, arrhythmia and myocardial edema following on pump cardiac surgery under optimized monitoring conditions. Of course, patients after uncomplicated cardiac surgery will not present major postoperative problems. Therefore, these patients were optimal in demonstrating clearly hemodynamic and physiologic alterations. These could assume that the need for inotropic agents, time to discharge time, mortality, aortic cross clamp time, extubation time, would be higher in DSC patients than in those patients without DSC. For future investigations, it is recommended that the demonstrated hemodynamic and fluid mobilizing effects be reproduced in severe and critically patients who present with manifest low cardiac output, bleeding, arrhythmia and myocardial edema following on pump cardiac surgery.
Delayed sternal closure is a safe and simple method for treating bleeding, arrhythmia, and myocardial edema following on pump cardiac surgery. It is effective in resolving the majority of patients without the addition of any significant morbidity and mortality. It is anticipated that as cardiac surgeons become more familiar with the technique of DSC, the frequency of its use following on pump cardiac surgery may increase.
Conflict of interest: None declared
This work was partly presented at the 57th ESCVS International Congress on Interactive Cardiovascular and Thoracic surgery, 24-27April, 2008, Barcelona, Spain
Accepted/Kabul Tarihi: 25.01.2010
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Address for Correspondence/Yazisma Adresi: Dr. Haydar Yasa, Ataturk Training and Research Hospital, Clinic of Cardiovascular surgery, izmir, Turkey Phone: +90 232 244 44 44 Fax: +90 232 243 48 48 E-mail: email@example.com
Haydar Yasa, Banu Bahriye Lafci, Levent Yilik, Mehmet Bademci, Aykut Sahin, Mert Kestelli, Murat Yesil * , Ali Gurbuz From Clinics of Cardiovascular Surgery and * Cardiology, Ataturk Training and Research Hospital, Izmir, Turkey
Table 1. Indications for DSC after 2698 cardiac operations Etiology number of the patients % Bleeding 21 0.77 Hemodynamic instability 16 0.59 Cardiac arrest 5 0.18 Arrhythmia 4 0.14 Total 46 1.7 Data are presented as numbers/percentages DSC--Delayed sternal closur Table 2. The distribution of open cardiac surgery and DSC procedures according to the diagnosis Surgical procedure No. of patients DSC. n(%) CABG 1746 15 (0.85) CABG+ valve surgery 91 2 (2.2) CABG + Carotid and 23 1 (4.3) peripheral vascular surgery CABG + arrhythmia surgery 9 -- CABG + Post MI VSD repair 7 1 (14.3) Valve surgery 453 12 (2.6) Valve + arrhythmia surgery 12 -- Aortic dissection and 104 10 (9.6) aneurysms Redo CABG 21 1 (4.3) Redo dissection 5 1 (20) Redo valve surgery 13 1 (7.6) Congenital cardiac surgery 207 2 (0.9) Other 15 -- Total 2698 46 (1.17) Data are presented as numbers-percentages CABG--coronary artery bypass surgery, DSC--delayed sternal closure. Ml--myocardial infarction, VSD--ventricular septal defect Table 3. Characteristics of patients with and without DSC Variables DSC(-) Patient age at time 55.0 [+ or -] 6.4 (1-84) of operation, years Bypass time, min 64 (27- 212) Aortic cross-clamp time, min 52(18-187) Postoperative days 2(1-17) until extubation Postoperative days until 5(4-102) hospital discharge Variables DSC(+) * P Patient age at time 57.0 [+ or -] 7.6 (2-73) NS of operation, years Bypass time, min 147(40-674) <0.05 Aortic cross-clamp time, min 87(68-349) <0.05 Postoperative days 7 (5-102) <0.05 until extubation Postoperative days until 16(15-116) <0.05 hospital discharge Data are presented as median (min-max) and meantSD (min-max) values * Mann Whitney U test DSC--delayed sternal closure, NS--not significant Table 4. Hemodynamic data Time period HR, beats/min Mean BR mm Hg Early post-op 96.4 [+ or -] 18.9 80.8 [+ or -] 15.7 Before closure 88.5 [+ or -] 20.2 92.5 [+ or -] 14.6 Early after closure 87.7 [+ or -] 18.4 90.3 [+ or -] 12.7 Time period CVP, mm Hg Mean PAP, mm Hg Early post-op 14.7+4.6 46 [+ or -] 6.7 Before closure 11.3 [+ or -] 2.4 35 [+ or -] 4.3 Early after closure 10.8 [+ or -] 3.0 * 35 [+ or -] 4.5 * Time period CI, L/min/[m.sup.2] Early post-op 2.4 [+ or -] 0.64 Before closure 2.8 [+ or -] 0.48 Early after closure 2.8 [+ or -] 0.44 Data are shown as mean [+ or -] SD * AN0VA for repeated measurements, p <0.05 BP -blood pressure, CI--cardiac index; CVP--central venous pressure; HR--heart rate; PAP--pulmonary artery pressure
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|Title Annotation:||Original Investigation/Ozgun Arastirma|
|Author:||Yasa, Haydar; Lafci, Banu Bahriye; Yilik, Levent; Bademci, Mehmet; Sahin, Aykut; Kestelli, Mert; Yes|
|Publication:||The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)|
|Date:||Apr 1, 2010|
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