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Physiologic effects of delayed sternal closure following stage 1 palliation

Published online by Cambridge University Press:  28 August 2018

Kimberly I. Mills ,
Sarah J. van den Bosch ,
Kimberlee Gauvreau ,
Catherine K. Allan ,
Ravi R. Thiagarajan ,
David M. Hoganson ,
Christopher W. Baird ,
Meena Nathan ,
James A. DiNardo  and
John N. Kheir
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.
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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.

Keywords

Stage 1 palliationNorwood proceduredelayed sternal closurehaemodynamicshypoplastic left heart syndrome
Type
Original Article
Information
Cardiology in the Young , Volume 28 , Issue 12 , December 2018 , pp. 1393 - 1403
Copyright
© Cambridge University Press 2018 

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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: 2081–2091.Google Scholar
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: 1556–1562.Google Scholar
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: 882–895.Google Scholar
4. Tweddell, JS, Hoffman, GM, Fedderly, RT, et al. Phenoxybenzamine improves systemic oxygen delivery after the Norwood procedure. Ann Thorac Surg 1999; 67: 161–167; discussion 167–168.Google Scholar
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: e003554–14.Google Scholar
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: 1094–1100.Google Scholar
7. Hakimi, M, Walters, HL, Pinsky, WW, Gallagher, MJ, Lyons, JM. Delayed sternal closure after neonatal cardiac operations. J Thorac Cardiovasc Surg 1994; 107: 925–933.Google Scholar
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: 886–893.Google Scholar
9. Shore, DF, Capuani, A, Lincoln, C. Atypical tamponade after cardiac operation in infants and children. J Thorac Cardiovasc Surg 1982; 83: 449–452.Google Scholar
10. Tyberg, JV, Grant, DA, Kingma, I, et al. Effects of positive intrathoracic pressure on pulmonary and systemic hemodynamics. Respir Physiol 2000; 119: 171–179.Google Scholar
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: 993–7–997.e1–2.Google 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: 234–238.Google Scholar
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: 2226–2235.Google Scholar
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.Google Scholar
15. Kay, PH, Brass, T, Lincoln, C. The pathophysiology of atypical tamponade in infants undergoing cardiac surgery. Eur J Cardiothorac Surg 1989; 3: 255–260; discussion 260–261.Google Scholar
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: 894–900.Google Scholar
17. Riphagen, S, McDougall, M, Tibby, SM, et al. ‘Early’ delayed sternal closure following pediatric cardiac surgery. Ann Thorac Surg 2005; 80: 678–684.Google Scholar
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: 1056–1062.Google Scholar
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: 289–300.Google Scholar