Eur J Cardiothorac Surg 2002;22:493-494
© 2002 Elsevier Science NL
What can be an indicator of delayed sternal closure after cardiac surgery?
Yoshio Misawa*
Division of Cardiovascular Surgery, Jichi Medical School, 3311-1 Yakushiji, Minami-kawachi, Tochigi, 329-0498, Japan
Received 1 June 2002;
accepted 4 June 2002.
* Tel.: +81-285-58-7368; fax: +81-285-44-6271
e-mail: tcvmisa{at}jichi.ac.jp
I read with great interest the paper entitled ‘Delayed sternal closure: a life-saving measure in neonatal open heart surgery; could it be predictable?’ in this Journal's May 2002 issue [1]. Samir and colleagues discussed the issues surrounding delayed sternal closure in neonate cardiac surgery. In their retrospective study of 312 consecutive open-heart procedures, 119 patients required delayed sternal closure while 21 needed reopening during the first 24 h. They mentioned that risk factors for delayed sternal closure or reopening included a cardiopulmonary bypass duration over 196 min, aortic clamping time over 106 min and central venous saturation below 47%. In addition, an age of less than 7 days and diagnoses of interruption of the aortic arch and total anomalous pulmonary venous drainage were also significant risk factors for delayed sternal closure.
Our earlier prospective study [2] in adult or infantile cardiac surgery indicated that sternal closure should be delayed when the mean left atrial or central venous pressure increase persisted at 2 mmHg or more above the initial value at the tentative sternal closure. Our study included 201 consecutive patients from between 1989 and 1991, of which seven were candidates and successfully underwent delayed sternal closure 6±3 days after the initial operation. No patient required sternal reopening because of hemodynamic deterioration. Longer cardiopulmonary bypass durations and ventricular fibrillation times were risk factors for delayed sternal closure, but aortic clamping time did not show any significant changes between patients with delayed sternal closure and those without.
Myocardial swelling, fluid accumulation in the mediastinum, low chest wall or lung compliance, patient profiles, and others factors might be related to postoperative hemodynamic instability. Longer cardiopulmonary and myocardial ischemia times per se did not offer direct cardiac compression, but did contribute to myocardial swelling and so on. Since 1989, we have had no case, other than for blood accumulation, requiring sternal reopening after cardiac surgery because of cardiac compression. Patient profiles between our study and Samir's were very different. However, we believe that mean left atrial and central venous pressures can reflect a new milieu after cardiac surgery produced by these factors affecting cardiac compression. Thus, we should rely on mean left atrial or central venous pressure rather than patient profiles or operation-related factors such as cardiopulmonary bypass time.
References
- Samir K., Riberi A., Ghez O., Ali M., Metras D., Kreitmann B. Delayed sternal closure: a life-saving measure in neonatal open heart surgery; could it be predictable?. Eur J Cardiothorac Surg 2002;21:787-793.[Abstract/Free Full Text]
- Misawa Y., Hasegawa T., Fukushima K., Sohara Y., Katoh M., Murayama F., Hasegawa N., Horimi H., Saito T., Yamaguchi T. Delayed sternal closure after cardiac surgery. Nippon Kyobu Geka Gakkai Zasshi 1992;40:1085-1088.[Medline]
