Between Hope and Risks; Insight on Delayed Sternal Closure Technique Outcomes in Adult Patients underwent Cardiac Operations

Abstract

Background: the delay of sternal closure after cardiac operations may offer the chance for survival in critical conditions; mainly sever hemodynamic instability and uncontrollable bleeding. Many concerns about hope of survival and possible risks especially mediastinitis or wound infection still represent dilemma for surgeons in such situations. The aim of our study is to evaluate the outcomes of delayed sternal closure technique after cardiac operations.Methods:this prospective study included 28 adult patients. Differentpreoperative, operative patient's data were collected and postoperative outcomes were recorded.Results: survival rate was 61% of patients; average time till sternal closure was 1.0±2.6 days. Main causes of death were multi-organ failure (n=4), low cardiac output (n=4), sepsis (n=3).Superficial sternotomy wound infection occurred in 3patients (10.7%) while only one patient developed deep sternotomy wound infection.Conclusions : delayed sternal closure is a beneficial technique that may carry the hope of survival for highly critical patients , risk of mediastinitis or wound infection were low and should not make the surgeon hesitate to offer the patient this valuable chance for survival when needed.

Early and Mid-Term Outcomes of Delayed Sternum Closure Strategy in Adult Cardiac Surgery: A Single-Center Experience

“…In the present study, 3.6% of our patients required DSC procedure, which is similar to recent studies that report an incidence between 3.5-5% [2,5,14], while other studies reported slightly lower incidences ranging between 1-2% [9,12,15] in adult patients. The most common indication for DSC in our center was hemodynamic instability and cardiac edema, followed by arrhythmia and diffuse bleeding, these indications were consistent with previous studies [5,6].…”

“…A broad variety of mortality rates were reported, which might be explained by a wide variation of preoperative and intraoperative risk factors, as well as the complexity of the procedures. Yasa et al [12] reported a mortality rate of 27%, Boeken et al [5] also in his large series of 179 patients reported an overall mortality of 29%, other studies reported higher rates of mortality over 30% [9,14,16]. On contrary, few studies with different numbers of patients and a variety of procedures reported less overall Heart Surgery Forum E215 mortality rates of 16% and 10% [11,17].…”

“…The timing of sternal closure is a critical choice that should be made with caution, as early closure might result in failure and recurrent cardiac dysfunction due to ongoing myocardial edema. While prolonged time to closure may expose the patient to increased risk of mortality [7,11] and sternal infections [9], some previous studies reported that they were unable to close the sternum before the 3rd postoperative day [7,11,21], and patients who were successfully closed were patients who required a low amount of inotropic support and in negative fluid balance [2,7]. In our study, the sternum was closed on a subsequent postoperative day in all of the patients except for one patient (mean time to closure was 21 hours ±7).…”

“…However, it would be unethical to perform such an analysis. Therefore, previous studies were either observational studies without comparison groups [8][9][10][11] or studies that included a control group of patients with primary sternal closure (PSC) who did not develop the same condition of hemodynamic compromise before weaning from CPB [2,4,5,12], which do not reflect the true efficacy of this procedure. In the present study, we presented our experience with DSC over 7 years to examine the early and mid-term outcomes in comparison with patients who exhibited hemodynamic instability on the termination of CPB, yet the sternum was closed primarily.…”