Delayed Sternal Closure after Congenital Heart Surgery in Infants: Postoperative Course
Delayed sternal closure in infants and children of the first months of life after the correction of complex congenital heart defects (CHD) can increase cardiac output. This is a forced measure due to the development of unstable hemodynamics, capillary leak syndrome and myocardial edema, as the sternotomy wound closure in the early postoperative period provides a compression effect on the function of the myocardium.
The aim. To evaluate mortality and to detect predictors of adverse outcome as well as the incidence of non-cardiac complications in delayed sternal closure after surgical repair of CHD.
Materials and methods. Twenty two children were studied. Six children died. Anesthetic management was provided using propofol (4–6 mg/kg/h) and fentanyl (5–10 μg/kg/h) infusions. Modified ultrafiltration was applied at the end of assisted circulation in all the cases. Sternal closure was performed on average on day 3 ± 2 after surgery.
Results. Mortality odds ratio (OR) in patients with the mean arterial pressure (MAP) < 35 mmHg was 3.7; mortality OR in patients with SVO2 < 40 % was 0.94; mortality OR in patients with blood lactate > 10 mmol/L in the first three days of postoperative intensive care was 2.1.
Conclusions. Delayed sternal closure is an acceptable method of maintaining cardiac output in young infants with CHD in postoperative period. High blood lactate (> 10 mmol/L) and especially its further growth, as well as MAP < 35 mmHg, can predict adverse outcomes of cardiac surgery with open sternotomy.
- van der Linde D, Konings EE, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJ, Roos-Hesselink JW. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. J Am Coll Cardiol. 2011; 58:2241–7. https://doi.org/10.1016/j.jacc.2011.08.025
- Prokopovych L, Golovenko O, Truba Y, Boyko S, Lazorishinetz V. [Surgical Treatment of Complex Coarctation of Aorta with Hypoplastic Aortic Arch in Infants]. Ukrainian Journal of Cardiovascular Surgery. 2016;1(24):61–4. Ukrainian.
- Harder EE, Gaies MG, Yu S, Donohue JE, Hanauer DA, Goldberg CS, Hirsch JC. Risk factors for surgical site infection in pediatric cardiac surgery patients undergoing delayed sternal closure. J Thorac Cardiovasc Surg. 2013 Aug;146(2):326–33. https://doi.org/10.1016/j.jtcvs.2012.09.062
- Hurtado-Sierra D, Calderón-Colmenero J, Curi-Curi P, Cervantes-Salazar J, Sandoval JP, García-Montes JA, et al. Outcomes of delayed sternal closure in pediatric heart surgery: single-center experience. Biomed Res Int. 2018 Apr 19;2018:3742362. https://doi.org/10.1155/2018/3742362
- Amato J. Review of the rationale for delayed sternal closure. Crit Care Med. 2000;28(4):1249–51. https://doi.org/10.1097/00003246-200004000-00072
- Abramyan MA. [Prolonged Open Sternotomy in Pediatric Cardiac Surgery]. Heart and Vessels Diseases in Children. 2005;6:18–25. Russian.
- Matsumoto M, Oka Y, Strom J, Frishman W, Kadish A, Becker RM, et al. Application of transesophageal echocardiography to continuous intraoperative monitoring of left ventricular performance. Am. J. Cardiol. 1980;46:95–105. https://doi.org/10.1016/0002-9149(80)90611-6
- Casha AR, Yang L, Kay PH, Saleh M, Cooper GJ. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg. 1999;15:365–69. https://doi.org/10.1016/s1010-7940(99)00014-7
- Del Nido PJ, Bichell DP. Minimal-access surgery for congenital heart defects. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 1998;1:75–80. https://doi.org/10.1016/s1092-9126(98)70010-9
- Manrique AM, Vargas DP, Palmer D, Kelly K, Litchenstein SE. The Effects of Cardiopulmonary Bypass Following Pediatric Cardiac Surgery. In: Munoz R, Morell V, da Cruz E, Vetterly C, da Silva J, editors. Critical Care of Children with Heart Disease. Springer, Cham; 2020. p. 113–29. https://doi.org/10.1007/978-3-030-21870-6_10
- Dönmez A, Yurdakök O. Cardiopulmonary bypass in infants. J Cardiothorac Vasc Anesth. 2014 Jun;28(3):778–88. https://doi.org/10.1053/j.jvca.2013.12.024