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Haemodynamic changes due to delayed sternal closure in newborns after surgery for congenital cardiac malformations

Published online by Cambridge University Press:  27 October 2009

Pavel Vojtovič ,
Oleg Reich ,
Marek Selko ,
Tomáš Tláskal ,
Jiří Hostaša ,
Tomáš Matějka ,
Roman Gebauer ,
Otakar Gabriel  and
Václav Chaloupecký
Pavel Vojtovič*
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Oleg Reich
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Marek Selko
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Tomáš Tláskal
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Jiří Hostaša
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Tomáš Matějka
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Roman Gebauer
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
Otakar Gabriel
Affiliation:
Department of Anaesthesiology and Intensive Care Medicine, 2nd Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
Václav Chaloupecký
Affiliation:
Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, Prague, Czech Republic
*
Correspondence to: Pavel Vojtovič, MD, Kardiocentrum and Cardiovascular Research Centre, University Hospital Motol, V úvalu 84, 150 08 Prague 5, Czech Republic. Tel: +420 22443 2900; Fax: +420 22443 2920; E-mail: pvojtovic@seznam.cz
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Abstract

Background

Delayed sternal closure is used to prevent low cardiac output syndrome in selected newborns shortly after cardiac surgery for congenital cardiac defects. Sternal closure itself often causes haemodynamic and ventilatory instability that cannot be entirely assessed by standard monitoring means. Therefore, we used transpulmonary thermodilution technique for an exact evaluation of the haemodynamic changes.

Patients and methods

Between April, 2006, and December, 2008, 23 neonates aged from 1 to 30 days, with a median of 7 days, and weighing from 1.9 to 4.2 kilograms, with a median of 3.25 kilograms, were studied after biventricular corrections. Residual intracardiac shunts were excluded by echocardiography. Haemodynamic and ventilatory parameters, along with those obtained by the transpulmonary thermodilution technique, were recorded before and immediately after the sternal closure, and then at 0.5, 1, 2, 6, 12, 24, and 48 hours.

Results

Chest closure caused significant decrease in systolic arterial pressure from 80.04 ± 11.48 to 69.48 ± 9.63 mmHg (p < 0.001), cardiac index from [median (25th/75th centile)] 2.640 (2.355/2.950) to 2.070 (1.860/2.420) l/min/m2 (p < 0.001), stroke volume index from 18.50 (16.00/20.00) to 14.00 (11.00/17.00) ml/m2 (p < 0.001), and dynamic lung compliance from 2.45 (2.31/3.00) to 2.30 (2.14/2.77) ml/cmH2O (p = 0.007). Stroke volume variation increased from 14.00 (9.25/16.75) to 18.00 (15.00/21.00) % (p < 0.001). The oxygenation index transitorily increased from 2.50 (2.14/3.15) to 3.36 (2.63/4.29) (p < 0.001). Serum lactate decreased from 1.40 (1.12/2.27) to 1.0 (0.8/1.3)mmol/l, p < 0.001 in coincidence with a haemodynamic stabilisation at a later time after chest closure. Cardiopulmonary instability caused by the sternal closure necessitated therapeutic intervention in 18 of 23 patients (78.3%).

Conclusion

Delayed sternal closure causes a significant transitory decrease in stroke volume, cardiac output and arterial blood pressure. Also lung compliance and blood oxygenation are temporarily significantly compromised.

Keywords

Infantscardiac outputcardiac functionthermodilutionpostoperative care
Type
Original Articles
Information
Cardiology in the Young , Volume 19 , Issue 6 , December 2009 , pp. 573 - 579
Copyright
Copyright © Cambridge University Press 2009

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