Physiologic effects of delayed sternal closure following stage 1 palliation

Norwood Operation: Immediate vs Delayed Sternal Closure

BACKGROUND

The Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications.

METHODS

This retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure).

RESULTS

The incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%).

CONCLUSIONS

For important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.

Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery

Objectives

Delayed sternal closure is a routine procedure to reduce hemodynamic and respiratory instability in pediatric patients following cardiac surgery, particularly in neonates and infants. In this setting, the possible links between sternal wound infection and delayed sternal closure are still a matter of debate. As a part of our routine, there was a low threshold for delayed sternal closure, so we reviewed our experience with sternal wound infections with a focus on potentially related perioperative risk factors, particularly delayed sternal closure.

Methods

We retrospectively identified 358 operated neonates (37%) and infants (mean age 3.6 months) in our local congenital heart disease database between January 2013 and June 2017. Potential risk factors for sternal wound infections, such as age, gender, complexity (based on Aristotle- and STS-EACTS mortality category), reoperation, use of cardiopulmonary bypass, extracorporeal membrane oxygenation, mortality and delayed sternal closure (163/358, 46%), were subjected to uni- and multivariate analysis.

Results

A total of 26/358 patients (7.3%) developed a superficial sternal wound infection. There were no deep sternal wound infections, no mediastinitis or sepsis. Applying univariate analysis, the prevalence of sternal wound infections was related to younger age, more complex surgery and delayed sternal closure. However, in multivariate analysis, sternal wound infection was only associated with delayed sternal closure (p = 0.013, odds ratio 8.6). Logistic regression revealed the prevalence of delayed sternal closure to be related to younger age, complexity, and the use of extracorporeal membrane oxygenation.

Conclusion

In patients younger than one year, sternal wound infections are clearly related to delayed sternal closure. However, in our cohort, all sternal wound infections were superficial and acceptable, considering the improved postoperative hemodynamic stability.

Outcomes of Delayed Sternal Closure in Paediatric Cardiac Surgical Patients–A Prospective Single Centre Study

Background Delayed sternal closure (DSC) is being increasingly used as an interim support to help the dysfunctional heart in the road to recovery after complex pediatric cardiac surgeries. The purpose of this study was to assess the conduct of DSC at a tertiary care center.

Methods Between 2018 and 2019, 185 consecutive pediatric patients (below 12 years of age) underwent cardiac surgery at a tertiary care center. The incidence and causes of DSC were noted. The various pre, intra and postoperative factors till discharge or demise were noted and analyzed.

Results In this study, DSC was done in 63 patients (34.05%) with a median age and weight of 29 days (18–100 days) and 4 kg (2–12.3 kg), respectively. Transposition of great arteries (TGA) (41.27%) constituted the majority, followed by total anomalous pulmonary venous connection (TAPVC) (26.98%). Myocardial edema (49.21%) was the most common indication for DSC. Mean duration of open chest was 40.75 ± 18.58 hours. All-cause mortality was 19.05% (12/63). On multivariate analysis by logistic regression, the independent predictors of mortality were needed for preoperative mechanical ventilation (OR 42.82, 95% CI = 4.52–406.03, p < 0.001) and development of postoperative sepsis (OR 20.07, 95% CI = 2.12–189.80, p = 0.002).

Conclusions DSC is a safe and effective technique in the management of complex pediatric cardiac surgeries. It provides assistance to the severely dysfunctional myocardium soon after the surgery and helps in stabilization of hemodynamics with avoidance of postoperative mediastinal compression. Early sternal closure should be considered on the basis of cardiovascular function and/or resolution of primary indication for DSC.