Skip to main content Accessibility help
×
Home
Hostname: page-component-684899dbb8-ct24h Total loading time: 0.34 Render date: 2022-05-24T23:01:49.095Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true }

Physiologic effects of delayed sternal closure following stage 1 palliation

Published online by Cambridge University Press:  28 August 2018

Kimberly I. Mills
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Sarah J. van den Bosch
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Kimberlee Gauvreau
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Catherine K. Allan
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
Ravi R. Thiagarajan
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
David M. Hoganson
Affiliation:
Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, USA Department of Surgery, Harvard Medical School, Boston, MA, USA
Christopher W. Baird
Affiliation:
Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, USA Department of Surgery, Harvard Medical School, Boston, MA, USA
Meena Nathan
Affiliation:
Department of Cardiovascular Surgery, Boston Children’s Hospital, Boston, MA, USA Department of Surgery, Harvard Medical School, Boston, MA, USA
James A. DiNardo
Affiliation:
Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
John N. Kheir*
Affiliation:
Departments of Cardiology, Boston Children’s Hospital, Boston, MA, USA Department of Pediatrics, Harvard Medical School, Boston, MA, USA
*
Author for correspondence: J. N. Kheir, MD, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +857 36 8890; Fax: +617 731 0787; E-mail: john.kheir@childrens.harvard.edu.

Abstract

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.

Type
Original Article
Copyright
© Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Newburger, JW, Sleeper, LA, Bellinger, DC, et al. Early developmental outcome in children with hypoplastic left heart syndrome and related anomalies: the single ventricle reconstruction trial. Circulation 2012; 125: 20812091.CrossRefGoogle ScholarPubMed
2. Pasquali, SK, Jacobs, JP, He, X, et al. The complex relationship between center volume and outcome in patients undergoing the Norwood operation. Ann Thorac Surg 2012; 93: 15561562.CrossRefGoogle ScholarPubMed
3. Tabbutt, S, Ghanayem, N, Ravishankar, C, et al. Risk factors for hospital morbidity and mortality after the Norwood procedure: A report from the Pediatric Heart Network Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144: 882895.CrossRefGoogle ScholarPubMed
4. Tweddell, JS, Hoffman, GM, Fedderly, RT, et al. Phenoxybenzamine improves systemic oxygen delivery after the Norwood procedure. Ann Thorac Surg 1999; 67: 161167; discussion 167–168.CrossRefGoogle ScholarPubMed
5. Mills, KI, Kaza, AK, Walsh, BK, et al. Phosphodiesterase inhibitor‐based vasodilation improves oxygen delivery and clinical outcomes following stage 1 palliation. J Am Heart Assoc 2016; 5: e00355414.CrossRefGoogle ScholarPubMed
6. Hoffman, GM, Mussatto, KA, Brosig, CL, et al. Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome. J Thorac Cardiovasc Surg 2005; 130: 10941100.CrossRefGoogle ScholarPubMed
7. Hakimi, M, Walters, HL, Pinsky, WW, Gallagher, MJ, Lyons, JM. Delayed sternal closure after neonatal cardiac operations. J Thorac Cardiovasc Surg 1994; 107: 925933.Google ScholarPubMed
8. Tabbutt, S, Duncan, BW, McLaughlin, D, Wessel, DL, Jonas, RA, Laussen, PC. Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg 1997; 113: 886893.CrossRefGoogle Scholar
9. Shore, DF, Capuani, A, Lincoln, C. Atypical tamponade after cardiac operation in infants and children. J Thorac Cardiovasc Surg 1982; 83: 449452.Google ScholarPubMed
10. Tyberg, JV, Grant, DA, Kingma, I, et al. Effects of positive intrathoracic pressure on pulmonary and systemic hemodynamics. Respir Physiol 2000; 119: 171179.CrossRefGoogle ScholarPubMed
11. Bacha, EA, Larrazabal, LA, Pigula, FA, et al. Measurement of technical performance in surgery for congenital heart disease: the stage I Norwood procedure. J Thorac Cardiovasc Surg 2008; 136: 9937–997.e1–2.CrossRefGoogle Scholar
12. Gaies, MG, Gurney, JG, Yen, AH, et al. Vasoactive–inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass*. Pediatr Crit Care Med 2010; 11: 234238.CrossRefGoogle ScholarPubMed
13. Wernovsky, G, Wypij, D, Jonas, RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 1995; 92: 22262235.CrossRefGoogle ScholarPubMed
14. Vojtovič, P, Reich, O, Selko, M, et al. Haemodynamic changes due to delayed sternal closure in newborns after surgery for congenital cardiac malformations. Cardiol Young. 2009; 19: 573.CrossRefGoogle ScholarPubMed
15. Kay, PH, Brass, T, Lincoln, C. The pathophysiology of atypical tamponade in infants undergoing cardiac surgery. Eur J Cardiothorac Surg 1989; 3: 255260; discussion 260–261.CrossRefGoogle ScholarPubMed
16. Horvath, R, Shore, S, Schultz, SE, Rosenkranz, ER, Cousins, M, Ricci, M. Cerebral and somatic oxygen saturation decrease after delayed sternal closure in children after cardiac surgery. J Thorac Cardiovasc Surg 2010; 139: 894900.CrossRefGoogle ScholarPubMed
17. Riphagen, S, McDougall, M, Tibby, SM, et al. ‘Early’ delayed sternal closure following pediatric cardiac surgery. Ann Thorac Surg 2005; 80: 678684.CrossRefGoogle ScholarPubMed
18. Rescoe, E, Tang, X, Perry, DA, et al. Cerebral near-infrared spectroscopy insensitively detects low cerebral venous oxygen saturations after stage 1 palliation. J Thorac Cardiovasc Surg 2017; 154: 10561062.CrossRefGoogle ScholarPubMed
19. Benjamini, Y, Hochberg, Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Series B, 57: 289300.Google Scholar
3
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Physiologic effects of delayed sternal closure following stage 1 palliation
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Physiologic effects of delayed sternal closure following stage 1 palliation
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Physiologic effects of delayed sternal closure following stage 1 palliation
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *