When Should the Sternum Be Closed After Aortic Surgery?

Abstract

Introduction: There are many factors affecting postoperative morbidity and mortality in patients managed with delayed sternal closure (DSC) after aortic surgery. This study aimed to examine the postoperative management of patients after DSC and the factors affecting morbidity and mortality. Patients and Methods: Among 2151 patients who underwent ascending aorta and/or aortic valve surgery between January 2012 and December 2020, 64 patients managed with DSC were included in the study. The records of the patients were obtained from the hospital archive/hospital electronic database. Postoperative day 30 was determined as early mortality. Results: Uncontrollable bleeding 34.4% (n= 22), LCOS (Low Cardiac Output Syndrome) 31.4% (n= 20) and mediastinal edema 28.1% (n= 18)were the main causes for DSC. In the remaining patients (6.3%, n= 4), DSC was preferred for other non-specific reasons such as uncontrollable arrhythmia. Forty-five patients’ chests (70.3%) were closed in the postoperative period, and 19 patients (29.7%) could not be closed due to death (p< 0.001). Early mortality was observed in 27 patients (42.2%), and sepsis was observed in 10 patients (15.6%). Deep sternal wound infection (DSWI) was present in 4.7% of the patients and the rate of sepsis was higher in this patient group (66.7%-13.1%, p< 0.05). There was no statistically significant difference in the probability of sepsis in the culture-positive patient group (p> 0.05). However, the closure time was longer in patients with a previous operation history, postoperative acute renal failure, surgical site infection, and postoperative bleeding revision/surgical revision (p< 0.05). Conclusion: DSC can be preferred as a life-saving method for various reasons such as bleeding diathesis, mediastinal edema, and malignant arrhythmia after open-heart surgery. Accurate timing and close follow-up are important for sternal closure. In these patients, a multidisciplinary approach is required in the postoperative period.

Keywords

• Thoracic surgery
• postoperative wound infection
• mediastinitis
• ascending aorta

References

1. 1. Boeken U, Assmann A, Mehdiani A, Akhyari P, Lichtenberg A. Open chest management after cardiac operations: outcome and timing of delayed sternal closure. Eur J Cardiothorac Surg 2011;40(5):1146-50. [Crossref]
2. 2. Christenson JT, Maurice J, Simonet F, Velebit V, Schmuziger M. Open chest and delayed sternal closure after cardiac surgery. Eur J Cardiothorac Surg 1996;10(5):305-11. [Crossref]
3. 3. Anderson CA, Filsoufi F, Aklog L, Farivar RS, Byrne JG, Adams DH. Liberal use of delayed sternal closure for postcardiotomy hemodynamic instability. Ann Thorac Surg 2002;73(5):1484-8. [Crossref]
4. 4. Shalabi RI, Amin M, Ayed AK, Shuhiber H. Delayed sternal closure is a life saving decision. Ann Thorac Cardiovasc Surg 2002;8(4):220-3.
5. 5. Ahmadi Tafti S, Karimi A, Gorabi A, Fathi F, Rezaei MR, Davoudi S, et al. Evaluation of open chest management (ocm) with delayed sternal closure (dsc) after cardiac surgery. Pakistan Hear J 2018;50(4):218-23.
6. 6. Wong JK, Joshi DJ, Melvin AL, Aquina CT, Archibald WJ, Lidder AK, et al. Early and late outcomes with prolonged open chest management after cardiac surgery. J Thorac Cardiovasc Surg 2017;154(3):915-24. [Crossref]
7. 7. Fanning WJ, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg 1987;44(2):169-72. [Crossref]
8. 8. Estrera AL, Porat EE, Miller CC 3rd, Meada R, Achouh PE, Irani AD, et al. Outcomes of delayed sternal closure after complex aortic surgery. Eur J Cardiothorac Surg 2008;33(6):1039-42. [Crossref]

9. 9. Shimokawa S, Toyohira H, Saigenji H, Fukuda S, Moriyama M, Koga M, et al. Delayed sternal closure following operation of type-a acute aortic dissection. Vasc Endovascular Surg 1995;29(4):281-5. [Crossref]
10. 10. Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017;51(1):10-29. [Crossref]
11. 11. Hashemzadeh K, Hashemzadeh S. In-hospital outcomes of delayed sternal closure after open cardiac surgery. J Card Surg 2009;24(1):30-3. [Crossref]
12. 12. Li M, Mazzeffi MA, Gammie JS, Banoub M, Pazhani Y, Herr D, et al. Characterization of postoperative infection risk in cardiac surgery patients with delayed sternal closure. J Cardiothorac Vasc Anesth 2020;34(5):1238-43. [Crossref]
13. 13. Stulak JM, Romans T, Cowger J, Romano MA, Haft JW, Aaronson KD, et al. Delayed sternal closure does not increase late infection risk in patients undergoing left ventricular assist device implantation. J Heart Lung Transplant 2012;31(10):1115-9. [Crossref]