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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sameh I. Sersar Ahmed A. Jamjoom Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Sersar, S. I. Articles by Jamjoom, A. A. PubMed Articles by Sersar, S. I. Articles by Jamjoom, A. A. Related Collections Mediastinum Cardiac - pharmacology Cardiac - physiology

Letters to the Editor

Open chest after cardiac surgery; revisited

Division of Cardiothoracic Surgery, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia

Received 2 July 2008; accepted 14 July 2008.

^_* Corresponding author. Address: MBC-J 16, P.O. Box 40047, Jeddah 21499, Saudi Arabia. Tel.: +966 2 667 7777x5234; fax: +966 2 6639581. (Email: Sameh001{at}yahoo.com).

Key Words: Open chest • Sternotomy • Mediastinitis

We read with interest the article entitled ‘Outcomes of delayed sternal closure after complex aortic surgery’ [1].

We congratulate the authors for their excellent results. However, they only mentioned the mediastinitis and graft infections as the outcomes although we expected some neurological, renal, gastrointestinal complications, septicaemia and/or multiorgan failures.

This is a retrospective study including a small number of open chest cases with the weaknesses of retrospective studies. In their study, Table 2 shows exploration in all survived patients {11} at least once, although the authors mentioned exploration in 5 patients only.

Mean left atrial and central venous pressures can reflect a new milieu after cardiac surgery produced by the factors affecting cardiac compression. Accordingly, it is wise to rely on mean left atrial or central venous pressure rather than patient profiles or operation-related factors such as cardiopulmonary bypass time as predictors of open chest requirement [2].

Delayed sternal closure (DSC) is leaving the chest opened for some time by delaying the closure of the sternum. There are two types of DSC.

1. Primary delayed sternal closure (PDSC) is delaying the sternal closure either as a principal method or after failure of one or several trials of closure at the end of the operation.

2. Secondary delayed sternal closure (SDSC) is the closure of the sternum that was primarily closed at the end of the operation and was reopened during the early postoperative period [3].

Did the authors have primary or secondary delayed sternal closures and if so, did they find any differences between both?

To make it more simple and practical, a rise of central venous pressure of more than 2–5 mmHg is a predictor for delayed sternal closure especially in higher risk cases such as CABG with ascending aortic surgery, CABG with valve surgery and carotid endarterectomy, redo and emergent cases with long cardiopulmonary bypass time, deep hypothermic circulatory arrest, TAPVD, IAA, TGA, tetralogy of Fallot with absent pulmonary valve, anomalous coronary anatomy, DKS and Norwood procedures [2–4].

PDSC is to be decided even without performing a trial of closure in cases of (a) presence of important bleeding of nonsurgical cause; (b) massive increase of the cardiac volume due to myocardial edema or dilatation or after the implantation of a homograft; and (c) need of high ventilatory pressures to maintain acceptable oxygen saturation.

The predictors of failure of primary sternal closure are either:

1. A drop in the heart rate, arterial blood oxygen saturation, central venous saturation and/or systemic arterial pressure.

2. An increase in the heart rate, left atrial pressure, central venous pressure, pulmonary artery pressure and/or airway pressure.

3. The appearance of arterial blood acidosis [3].

Good sternal wound closure and sternal approximation are the most important factors that decrease the incidence of mediastinitis. So the method of sternotomy closure, material and size of sutures can affect the incidence of mediastinitis.

According to Losanoff and colleagues, peristernal single wires followed by alternative peristernal transsternal single wires are the best methods for the mechanical stability of all the sternotomies. Peristernal figure of eight, Robicsek, multiple transsternal wires are less effective methods and pericostal figure of eight wires are the least effective [5].

Although we believe that open chest management does not appear to increase the risk of infection (mediastinitis or graft infections) during complex proximal aortic replacement, administration of vancomycin and ceftazidime for 5 days post chest closure may be a good idea.

References

1. Estrera AL, Porat EE, Miller CC, Meada R, Achouh PE, Irani AD, Safi HJ. Outcomes of delayed sternal closure after complex aortic surgery. Eur J Cardiothorac Surg 2008;33:1039-1042.[Abstract/Free Full Text]
2. 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]
3. 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]
4. Christenson JT, Maurice J, Simonet E, Velebit V, Schmuziger M. Open chest and delayed sternal closure after cardiac surgery. Eur J Cardiothorac Surg 1996;10:305-311.[Abstract]
5. Losanoff JE, Collier AD, Wagner-Mann CC, Richman BW, Huff H, Hsieh F, Diaz-Arias A, Jones JW. Biomechanical comparison of median sternotomy closures. Ann Thorac Surg 2004;77:203-209.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. L. Estrera and H. J. Safi Reply to Sersar et al. Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 930 - 930. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sameh I. Sersar Ahmed A. Jamjoom Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Sersar, S. I. Articles by Jamjoom, A. A. PubMed Articles by Sersar, S. I. Articles by Jamjoom, A. A. Related Collections Mediastinum Cardiac - pharmacology Cardiac - physiology