Delayed Sternal Closure Following Complex Cardiac Surgery in Neonates

Abstract

Background

Delayed sternal closure (DSC) is a well-established management strategy following complex congenital cardiac surgery that is used to mitigate postoperative hemodynamic and respiratory instability. It is mostly used in neonates requiring prolonged cardiopulmonary bypass (CPB), long aortic cross-clamp times, or deep hypothermic circulatory arrest who are predisposed to myocardial edema or bleeding. Our study evaluates morbidity and mortality after DSC in neonates including superficial and deep sternal wound infections, along with requirement for surgical debridement.

Methods

Retrospective review of neonates who underwent DSC after cardiac surgery at a single center from 2015 to 2021.

Results

A total of 187 neonates were identified. Mean age and weight were 12.8 ± 6.8 days and 3.3 ± 0.5 kg, respectively. Mean days of open chest were 3.8 ± 5.8 days. Two neonates (1.07%) required sternal wound debridement, while 19 cases (10.2%) had superficial wound infections. Mean intensive care unit (ICU) and hospital stay were 12.8 ± 16.6 and 25.9 ± 36.9 days, respectively; 30-day mortality occurred in nine of 187 cases (4.8%). Univariate analysis indicated that DSC days (P = .01), extracorporeal membrane oxygenation (ECMO) (P = .000), aortic cross clamp time (P = .007), and CPB time (P = .006) were associated with 30-day mortality, while in multivariable analysis, only ECMO was significant (P = .002). Risk Adjustment for Congenital Heart Surgery (RACHS-1) score was the only independent risk factor for sternal wound infection in univariate analysis (P = .019) and multivariable analysis (P = .05).

Conclusion

Delayed sternal closure is a safe therapeutic option following complex neonatal cardiac surgery, where cardiac compression by sternal approximation is not tolerated due to myocardial edema, hemodynamic instability, or coagulopathy. Higher RACHS-1 score was associated with a greater incidence of sternal wound infections.