Acute type a aortic intramural hematoma complicated with preoperative hemopericardium: early and late surgical outcome analyses.

BACKGROUND: Acute type A aortic intramural hematoma (ATAIMH) is a variant of acute type A aortic dissection (ATAAD), exhibiting an increased risk of hemopericardium and cardiac tamponade. It can be life-threatening without emergency treatment. However, comprehensive studies of the clinical features and surgical outcomes of preoperative hemopericardium in patients with ATAIMH remain scarce. This retrospective study aims to investigate the clinical features and early and late outcomes of patients who underwent aortic repair surgery for ATAIMH complicated with preoperative hemopericardium. METHODS: We investigated 132 consecutive patients who underwent emergency ATAIMH repair at this institution between February 2007 and August 2020. These patients were dichotomized into the hemopericardium (n = 58; 43.9%) and non-hemopericardium groups (n = 74; 56.1%). We compared the clinical demographics, surgical information, postoperative complications, 5-year cumulative survival rates, and freedom from reoperation rates. Furthermore, multivariable logistic regression analysis was utilized to identify independent risk factors for patients who underwent re-exploration for bleeding. RESULTS: In the hemopericardium group, 36.2% of patients presented with cardiac tamponade before surgery. Moreover, the hemopericardium group showed higher rates of preoperative shock and endotracheal intubation and was associated with an elevated incidence of intractable perioperative bleeding, necessitating delayed sternal closure for hemostasis. The hemopericardium group exhibited higher blood transfusion volumes and rates of re-exploration for bleeding following surgery. However, the 5-year survival (59.5% vs. 75.0%; P = 0.077) and freedom from reoperation rates (93.3% vs. 85.5%; P = 0.416) were comparable between both groups. Multivariable analysis revealed that hemopericardium, cardiopulmonary bypass time, and delayed sternal closure were the risk factors for bleeding re-exploration. CONCLUSIONS: The presence of hemopericardium in patients with ATAIMH is associated with an elevated incidence of cardiac tamponade and unstable preoperative hemodynamics, which could lead to perioperative bleeding tendencies and high complication rates. However, patients of ATAIMH complicated with hemopericardium undergoing aggressive surgical intervention exhibited long-term surgical outcomes comparable to those without hemopericardium.

Delayed Sternal Closure Using a Vacuum-Assisted Closure System in Adult Cardiac Surgery.

Background: Delayed sternal closure (DSC) is a useful option for patients with intractable bleeding and hemodynamic instability due to prolonged cardiopulmonary bypass and a preoperative bleeding tendency. Vacuum-assisted closure (VAC) has been widely used for sternal wound problems, but only rarely for DSC, and its efficacy for mediastinal drainage immediately after cardiac surgery has not been well established. Therefore, we evaluated the usefulness of DSC using VAC in adult cardiac surgery. Methods: We analyzed 33 patients who underwent DSC using VAC from January 2017 to July 2022. After packing sterile gauze around the heart surface and great vessels, VAC was applied directly without sternal self-retaining retractors and mediastinal drain tubes. Results: Twenty-one patients (63.6%) underwent emergency surgery for conditions including type A acute aortic dissection (n=13), and 8 patients (24.2%) received postoperative extracorporeal membrane oxygenation support. Intractable bleeding (n=25) was the most common reason for an open sternum. The median duration of open sternum was 2 days (interquartile range [25th-75th pertentiles], 2-3.25 days) and 9 patients underwent VAC application more than once. The overall in-hospital mortality rate was 27.3%. Superficial wound problems occurred in 10 patients (30.3%), and there were no deep sternal wound infections. Conclusion: For patients with an open sternum, VAC alone, which is effective for mediastinal drainage and cardiac decompression, had an acceptable superficial wound infection rate and no deep sternal wound infections. In adult cardiac surgery, DSC using VAC may be useful in patients with intractable bleeding or unstable hemodynamics with myocardial edema.

Impact of time to chest closure on early and late survival in adults with delayed sternal closure.

OBJECTIVES: Delayed sternal closure (DSC) after cardiac surgery is a temporizing measure to address coagulopathy or haemodynamic instability after cardiac surgery. We sought to study: (i) indications and temporal trends for DSC, (ii) factors associated with time to chest closure and (iii) its impact on short-term and long-term outcomes. METHODS: From January 2007 to December 2017, 494 patients (median age 67 years, 66% males) required DSC after cardiac surgery. Medical records were reviewed for indications, risk factors, time to DSC and outcomes. Multivariable Cox regression via landmark analysis of 486 5-day survivors was used to investigate the impact of time to chest closure on early and late survival. RESULTS: Coagulopathy and haemodynamic instability were the most common indications. Median time to chest closure was 2 days. Pre-/intraoperative extracorporeal membranous oxygenation, severe right ventricular dysfunction and diabetes mellitus were associated with longer time to chest closure. Longer time to closure was associated with increased risk of operative complications and operative mortality, but did not have a statistically significant association with late mortality. Increasing age, pulmonary hypertension and a greater number of prior sternotomies were also found to be associated with overall mortality. CONCLUSIONS: While longer time to chest closure was associated with increased rates of operative complications and operative mortality, it did not reveal a statistically significant association with long-term survival.

Infant heart transplantation with extremely oversized donor heart: is the donor-recipient size matching too conservative?

Heart transplantation (HTx) remains the gold standard treatment for end-stage heart failure in children but is restricted due to the limitation of donors. The donor-recipient weight ratio (DRWR) of 0.8-2.5 was the main selection criterion, and reports were particularly scarce in cases of DRWR > 3.0. We present an infant HTx case with DRWR of 6.5. The recipient was a 66-day-old female infant, weighing 3 kg, diagnosed with complex congenital heart disease and refractory severe heart failure, whereas the donor was a 4-year-old girl weighing 19.5 kg. The phased delayed sternal closure was performed and accomplished on the 23rd day after operation without wound infection. After treating complications with extracorporeal membrane oxygenation, peritoneal dialysis, and mechanical ventilation, the patient was successfully discharged. After 1 year of follow-up, the patient was still in optimal condition. Extending DRWR range may help enlarge the donor pool and shorten recipients' waiting time.

Delayed sternal closure for intractable bleeding after acute type A aortic dissection repair: outcomes and risk factors analyses.

BACKGROUND: Perioperative coagulopathy and intractable bleeding are severe complications in acute type A aortic dissection (ATAAD) repair surgery. Mediastinal packing with delayed sternal closure (DSC) is a commonly adapted technique to stabilize the hemorrhagic tendency. This retrospective study aims to investigate the early and late outcomes and risk factors in patients who underwent DSC procedure during ATAAD repair surgery. METHODS: This study investigated 704 consecutive patients who underwent ATAAD repair at this institution between January 2007 and September 2020. These patients were dichotomized into the DSC (n = 109; 15.5%) and primary sternal closure (PSC) groups (n = 595; 84.5%). The clinical features, surgical information, postoperative complications, 5-years cumulative survival, and freedom from reoperation rates were compared. A multivariate logistic regression analysis was used to identify the independent risk factors for patients who underwent DSC. RESULTS: The DSC group showed a higher rate of hemopericardium and preoperative malperfusion, and was associated with longer cardiopulmonary bypass and aortic clamping times and a higher rate of intraoperative extracorporeal membrane oxygenation (ECMO) support. The DSC group showed higher blood transfusion volumes and rate of reexploration for bleeding after surgery. However, the in-hospital mortality rates (17.4% vs. 13.3%; P = 0.249), 5-year survival rates (66.9% vs. 68.2%; P = 0.635), and freedom from reoperation rates (89.1% vs. 82.5%; P = 0.344) were comparable between the DSC and PSC groups. Multivariate analysis revealed that hemopericardium, preoperative malperfusion, and intraoperative ECMO support were risk factors for implementing DSC. CONCLUSIONS: DSC is an efficient life-saving technique to stabilize patients with intractable bleeding after undergoing ATAAD repair surgery, which leads to acceptable short- and long-term outcomes. Patients who were at risk for intractable bleeding should have early decision-making for implementing DSC.

Feasibility of open chest management with modified negative pressure wound therapy immediately after cardiac surgery.

OBJECTIVES: To evaluate the feasibility of open chest management with our modified negative pressure wound therapy immediately after cardiac surgery as a therapy for atypical tamponade. METHODS: Open chest with modified negative pressure wound therapy was performed immediately after cardiac surgery. The surface of the heart and the vessels were covered with non-adherent siliconized gauze. The sternal halves were stented using edge-cut disposable syringes to maintain a larger mediastinal cavity. Approximately 45 mm of distance was kept between the sternal edges. A trimmed sterile polyvinyl foam sponge was inserted into the mediastinum, the entire wound was sealed and negative pressure (-50 to -75 mmHg) was applied using a suction generator. Delayed chest closure was performed in a standard manner once the haemodynamic status was stabilizsed. RESULTS: The mortality rate was 3/15 (20%) patients. Deep sternal wound infection occurred in 1/15 (6.7%) patients. Five patients were extubated during the open chest management. Sternal closure was delayed for median of 3 days after the initial surgery. There was no incidence of bleeding complications or need for additional haemostatic procedures. CONCLUSIONS: Negative pressure wound therapy performed immediately after cardiac surgery was feasible in our small number of patients. CLINICAL REGISTRATION NUMBER: Study ID: 2020-149.

Use of hydrocolloid dressing in infants requiring open chest management after cardiac surgery.

PURPOSE: Sternal splintage is known as an effective maneuver to stabilize hemodynamics during the immediate postoperative period, particularly in very sick infants. On the other hand, its wound management is not always straightforward. We employed dressing using a product made of a hydrocolloid material in such circumstances. This report describes our experience in utilizing the dressing in term of its potential advantages. MATERIALS AND METHODS: Six infants needed open chest management following complicated procedures for congenital heart disease. A polytetrafluoroethylene patch was fixed to augment the skin defect at the time of sternal splintage, and a hydrocolloid dressing was applied to entirely cover the wound including the suture line. RESULT: All patients survived their difficult circumstances. None of them suffered wound complications such as infection or healing problem during sternal splintage or subsequent to eventual chest closure. The dressing product was easy to handle with no adverse events associated with its material. CONCLUSIONS: It is reconfirmed that a dressing made of hydrocolloid material was of practical use for sealing the wound in infants requiring open chest management after cardiac surgery.

A Nano-Silver Loaded PVA/Keratin Hydrogel With Strong Mechanical Properties Provides Excellent Antibacterial Effect for Delayed Sternal Closure.

Delayed chest closure (DSC) is widely performed during the treatment of congenital heart diseases. However, the high prevalence of surgical site infection (SSI) in patients undergoing DSC affects prognosis negatively. Herein, we designed a suturable poly (vinyl alcohol)/keratin film loaded with silver nanoparticles (AgNPs) as an alternative material for DSC, which was named PVA/Keratin/AgNPs. The PVA/Keratin/AgNPs films exhibited significantly enhanced mechanical strength after crosslinking by sodium trimetaphosphate (STMP). These films were non-toxic, and cells proliferated with good morphology after 1 week of culture. In addition, PVA/Keratin/AgNPs films provided superior antibacterial ability, as evidenced by the eradication and lower growth rate of Staphylococcus aureus and Escherichia coli. Finally, the PVA/Keratin/AgNPs films were demonstrated to successfully cover the chest cavity temporarily and protect the chest cavity from bacterial infection. These results indicated that the PVA/Keratin/AgNPs films have great prospects to be further exploited for clinical applications in DSC.

Early Versus Late Sternal Closure in Infants-Perioperative Associations and Outcomes.

BACKGROUND: Delayed sternal closure (DSC) has been used for patients who develop bleeding, chest wall edema, and malignant arrhythmia following cardiopulmonary bypass. Multiple factors can influence the timing of when to perform DSC. We aimed to describe our DSC experience in neonates and infants by comparing outcomes between patients undergoing early (<48 hours) versus late DSC (> 48 hours). We explored the associations between specific clinical and laboratory variables and the timing of DSC. METHODS: Retrospective chart review of neonates and infants (

Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study.

OBJECTIVES: To determine the prevalence of surgical site infections (SSIs) in neonatal congenital heart disease patients undergoing delayed sternal closure (DSC) and evaluate risk factors for SSI. METHODS: Hospital records of 483 consecutive neonates who underwent surgical intervention between January 2013 and December 2017 were reviewed, and perioperative variables were recorded. RESULTS: We found that the prevalence of SSI was 87.5% when the body weight was less than 1500 g. When the operative age was between seven and 14 days, the probability of no SSI is about 93.9%. When the duration of the aortic cross-clamp was more than 60 min, the prevalence of SSI was 91.2%. The prevalence without SSI was 96.6% when the duration of DSC was less than 24 h. However, when the duration of DSC was more than 120 h, the prevalence of SSI was 88.9% (p = 0.000). CONCLUSIONS: With the prolongation of aortic clamping duration, the probability of occurrence of SSI increased in neonatal CHD with DSC. The age at operation and body weight are closely related to the occurrence of SSI in neonatal CHD patients with DSC.

Using eye speculum as a sternal retractor for delayed sternal closure after pediatric heart surgery.

Sternal closure can lead to hemodynamic and respiratory instability after some complex pediatric cardiac surgeries. In such cases, delayed sternal closure is applied to facilitate postoperative recovery. During open sternum several instruments have been defined to prevent the sternum from compressing the heart; however, most of them have limitations. We, therefore, have attempted to use a new instrument to keep the sternum open in neonates and infants. This instrument has been used as an adult eye speculum which is made of a flexible metal wire. It is delicate, ready to use, easily placed, and good fitted to the pediatric sternal edges.

Outcomes of primary sternal closure for postoperative mediastinitis in children.

OBJECTIVES: We retrospectively analysed outcomes of debridement and primary sternal closure for postoperative mediastinitis in children. METHODS: Between January 2007 and July 2019, 1285 patients under the age of 20 years underwent congenital heart surgery at the Iwate Medical University. Of these, 22 children had postoperative mediastinitis (1.7%). We performed adequate debridement and primary sternal closure with pectoralis major muscle advancement flaps. We evaluated hospital survival rates, reintervention, duration of intravenous antibiotic treatment, intensive care unit (ICU) stay and hospital stay. RESULTS: The median age and weight at surgery were 12.5 months (range 0-228 months) and 7.8 kg (range 2.2-64.2 kg), respectively. Two patients (9%) had a history of delayed sternal closure. Staphylococcus was the most common causative agent for infection (82%). All cases were categorized as Robicsek's classification type II mediastinitis. The hospital survival rate was 95%, and freedom from reintervention for infectious complications was observed in 91% of the patients. The median durations of intravenous antibiotic treatment, ICU stay and hospital stay were 18 days (range 9-46 days), 4 days (range 1-87 days) and 22.5 days (range 11-87 days). The median follow-up time was 89 months (range 2-148 months), and there was no evidence of recurrent mediastinitis, musculoskeletal growth, physical deformity, breast development and upper trunk or limb movement. CONCLUSIONS: Primary sternal closure is an effective procedure for children as it can significantly shorten treatment duration and reduce physical and psychological burdens. Its results compare favourably with those of conventional therapy in terms of mortality and complications.

A Quality Improvement Initiative to Reduce Surgical Site Infections in Patients Undergoing Delayed Sternal Closure After Pediatric Cardiac Surgery.

Sternal wound infections (SWI) in delayed sternal closure (DSC) patients are a healthcare burden after congenital heart surgery. There are no guidelines specific for pediatric DSC patients to prevent this costly complication. The hypothesis was that the modifications to a bundled approach for DSC patients would decrease the SWI rate. For this prospective cohort study, DSC patients were postoperatively admitted to a pediatric cardiac care unit from February 2017 to January 2018. Using a modified protocol for prevention of SWI, the infection rates pre- and post-modified protocol were compared. The primary outcome measure was SWI. Secondary outcome measures were compliance with modifications. Retrospective review of cases in pre-protocol modification era from January 1, 2014 to December 31, 2016 showed 377 pediatric cardiopulmonary bypass cases and 39 (10.4%) underwent DSC. During the post-protocol modification era, there were 129 cardiopulmonary bypass cases and 17 (13%) DSC cases. The SWI rate in DSC were 7.7% and 0% for pre-intervention and post-intervention, respectively (p = 0.52). The Bayesian confidence interval with Jeffreys prior gives a 95% confidence interval of 1.5% to 18.3% for pre-intervention and 0 to 13.5% for post-intervention. Compliance with the protocol bundle during the post protocol era was 93-100%. Although preliminary results are not statistically significant due to cohort size, the economic burden and increased LOS for each SWI is clinically significant. The early results of reduced infections for DSC patients using a modified bundle approach appear promising. Continued study and a multicenter project would be beneficial.

Efforts to Reduce Infections in Delayed Sternal Closure Patients: A Survey of Pediatric Practice.

BACKGROUND: Pediatric patients with sternum left open after cardiac surgery experience a higher risk for sternal wound infection (SWI). These infections are costly for programs, payers, and patients and their families. Despite efforts by individual programs to reduce infections in patients undergoing delayed sternal closure (DSC), there are no established guidelines that address preventive procedures. The purpose of this study was to determine the practice of pediatric cardiac surgery programs to prevent infection in their DSC patients and if preventive measures were associated with less infections. METHODS: A 33 question survey on institutional practices was sent to chief surgeons at pediatric cardiac surgery programs in the United States. RESULTS: Twenty-eight (35%) surgical programs responded. The mean number of pediatric cardiac bypass operations performed by programs in 2016 was 227 (range: 69-872). Data represented 6,484 patients <18 years of age who underwent cardiac surgery with 807 (12%) of those undergoing DSC. One hundred fifty-eight (2.4%) of all patients and 51 (6.3%) of the DSC patients developed a SWI. Patients with DSC who received preoperative baths were less likely to become infected (5.9% vs 15.8%; P = .015). Patients in programs with feeding protocols had fewer infections (5.7% vs 14.8%; P = .008). CONCLUSIONS: The results of this survey of children's cardiac surgery programs describe their practices to reduce infection rates in DSC patients. A multicenter project on wound care and closure techniques that might impact this costly complication is needed.

Characterization of Postoperative Infection Risk in Cardiac Surgery Patients With Delayed Sternal Closure.

OBJECTIVES: To compare the incidence of postoperative infection in cardiac surgery patients who had delayed sternal closure (DSC) with those who had primary sternal closure (PSC) and evaluate the effectiveness of antibiotic prophylaxis in DSC patients. DESIGN: Retrospective, observational cohort study with propensity score matching. SETTING: Single academic medical center. PARTICIPANTS: Cardiothoracic surgery patients, excluding transplantation patients, from a single academic medical center who had DSC or PSC between November 2015 and November 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,685 patients who had cardiac surgery with cardiopulmonary bypass, 99 had DSC. Fifty-nine DSC patients met study inclusion criteria, and the final propensity score matched cohort included 57 patients with DSC and 57 patients with PSC. Propensity score matching reduced bias but was unable to balance all covariates. The most common indication for DSC was coagulopathy in 32 of the 57 patients. All patients in the PSC group received routine antibiotic prophylaxis for 48 hours after surgery. Patients in the DSC group received prolonged broadened prophylaxis until 48 hours after sternal closure. Despite prolonged broadened antibiotic prophylaxis, the DSC group had a higher rate of postoperative infection (31.6% v 3.5%; p < 0.005), mainly pneumonia (19.3% v 1.8%; p < 0.005), in the first 30 days after surgery. There was no difference in the incidence of sepsis (5.3% v 0%; p = 0.24), superficial skin and soft tissue infection (1.8% v 1.8%; p = 1), or mediastinitis/deep tissue infection (5.3% v 0%; p = 0.24) in patients with DSC. Seventy-seven percent of causative organisms for infection were Gram-negative bacteria in the matched cohort. CONCLUSION: The incidence of postoperative infection, particularly pneumonia, is high in cardiothoracic surgery patients with DSC, even with prolonged broadened antibiotic prophylaxis, but the rate of mediastinitis/deep tissue infection did not appear to be greater with DSC. Additional research is needed into optimal antibiotic prophylaxis in this high-risk group of patients.

Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature.

Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.

Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study.

INTRODUCTION: Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same. METHODS: We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients. RESULTS: A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%. CONCLUSION: In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.

Physiologic effects of delayed sternal closure following stage 1 palliation.

BACKGROUND: Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection. METHODS: We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure. RESULTS: During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment. CONCLUSION: When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.

Sternal semi-closure using a bioresorbable osteosynthesis device: a new method for delayed sternal closure.

PURPOSE: To evaluate the safety and efficacy of our new delayed sternal closure (DSC) method, involving sternal semi-closure using a bioresorbable osteosynthesis device and complete skin closure. METHODS: Between 2013 and 2017, 36 patients underwent DCS at our hospital. The patients were divided into two groups based on the method used for DSC. The later conventional DSC group consisted of 18 patients undergoing late complete sternal closure following fixation of pulmonary and hemodynamic instability, and the new DSC group consisted of 18 patients undergoing early sternal semi-closure a few days after surgery. In the new DSC group, the sternum was fixed with Super Fixsorb MX40, followed by complete skin closure. RESULTS: Respiratory and hemodynamic conditions, such as systolic blood pressure, cardiac index, tidal volume, and regional oxygen saturation, were significantly more stable in the new DCS group than in the conventional DSC group. The hospital stay was also significantly shorter in the new DSC group. Although there were no serious complications, one patient from the new DCS group suffered deformity of the sternum, which was managed successfully. CONCLUSION: The sternal semi-closure method decreases pulmonary and cardiac instability during DSC, making early DSC possible.

Delayed sternal closure does not reduce complications associated with coagulopathy and right ventricular failure after left ventricular assist device implantation.

Delayed sternal closure (DSC) is occasionally adopted after implantation of left ventricular assist device (LVAD). Recent studies suggest that DSC be used for high risk group of patients with coagulopathy, hemodynamic instability or right ventricular failure. However, whether DSC is efficacious for bleeding complication or right ventricular failure is not known. This study is single center analysis of 52 patients, who underwent LVAD implantation. Of those 52 patients, 40 consecutive patients underwent DSC routinely. The sternum was left open with vacuum assist device after implantation of LVAD. Perioperative outcome of the patients who underwent routine DSC were compared with 12 patients who had immediate sternal closure (IC). Mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level of IC group and DSC group were 2.7 and 2.6, respectively. Postoperative bleeding (643 vs. 1469 ml, p < 0.001), duration of inotropic support (109 vs. 172 h, p = 0.034), and time to extubation (26 vs. 52 h, p = 0.005) were significantly increased in DSC group. Length of ICU stay (14 vs. 15 days, p = 0.234) and hospital stay (28 vs. 20 days, p = 0.145) were similar. Incidence of right ventricular failure and tamponade were similar in the two groups. Routine DSC after implantation of an LVAD did not prove to be beneficial in reducing complications associated with coagulopathy and hemodynamic instability including cardiac tamponade or right ventricular failure. We suggest that DSC be selectively applied for patients undergoing LVAD implant.