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Eur J Cardiothorac Surg 2002;22:494
© 2002 Elsevier Science NL
Letter to the Editor |
Sce Pr Metras, La Timone Enfant, La Timone University Center, Marseille F-13005, France
Received 3 June 2002; accepted 4 June 2002.
e-mail: ksam68{at}yahoo.com
We would like to thank Dr Misawa for his comments which helped us to have a better idea about his study.
The stimulus of our study was the high mortality and morbidity in the group of patients who needed emergency sternal reopening in the early postoperative period despite their temporary apparent hemodynamic stability at the end of the operation. After revising the literature we were confronted with many articles discussing the safety of the procedures but none of them discussed decision making.
We have chosen to study the problem in a pure neonatal community in which the procedure is usually life saving. We have studied many of the suspected factors that are thought to be associated with delayed sternal closure (DSC) [1]. To our mind the pseudo sternal tamponade syndrome results because of the change of cardiac volume (myocardial edema, dilatation of one or more cardiac chambers, tissue or prosthetic implantation), cardiac geometry, especially the antero-posterior diameter (mode of repair, lateral compression by the lungs), and mediastinal restriction (drains, clots). Our results seem logic as regards clamping and CPB times (increased myocardial and lung edema and the need for higher respiratory pressures), low central venous saturation (reflects low cardiac output which associates with the diastolic dysfunction) and an age of less than 7 days. On the other hand we were surprised with the body weight and the use of hypothermic arrest being of no statistical importance.
Misawa et al. had a completely different group of 201 patients including adults with seven DSC (3.5%) with two late mortalities [2]. They confirmed the safety of the technique and mentioned CPB time, VF duration and an increase of 2 mmHg or more in LA pressure or CVP.
The difference in LA pressure before and after the procedure was not statistically estimated in our study as a predicting factor as we do not routinely measure it before the procedure and this difference per se was not suspected as a factor associated with the need for DSC; however, we can say that in neonates an increase in LA pressure by 2 mmHg or even more is considered acceptable due to an expected LV dysfunction during the immediate postoperative period that can be often controlled by inotropism. We studied the changes in LAP and CVP after the trial of closure and a rise of more than 5 mmHg was a contraindication for closure.
It is obvious that the need of DSC decreases with age and it becomes a rare manoeuvre in adults (mostly for bleeding or after tissue or prosthetic implantation).
We think that the two studies are incomparable as they are discussing two completely different issues although both of them ensure the safety of the technique and the need for more studies from other centres to confirm these risk factors and the predictability of the need for DSC aiming finally at holding a risk score to render the decision making for DSC more objective.
References
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