Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery

BACKGROUND Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening. METHODS We reviewed patients aged < 18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC 52 days (98 patients), PDSC > 2 days (81 patients), and SDSC (45 patients) were analyzed. RESULTS Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC > 2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC > 2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC 52 and 6.2% for PDSC > 2 days, P < .01). Hospital stay was longer in SDSC (57 +/- 7 days) than PDSC 52 days (22 +/- 5 days) and PDSC > 2 days (44 +/- 6, P = .01). Survival was better in PDSC regardless of duration than SDSC. CONCLUSIONS PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes. (c) 2022 by The Society of Thoracic Surgeons

Automated summary

This study found that delayed sternal closure (DSC) yielded better outcomes for hemodynamic instability and severe coagulopathy after complex congenital heart surgery compared to perioperative sternal reopening.