Commentary: Delayed sternal closure—an open and not-so-shut case

Central MessageA randomized study is required to determine whether closing the skin and soft tissues over an open sternum reduces the risk of sternal wound infection in these critically ill cardiac surgery patients.See Article page 77. A randomized study is required to determine whether closing the skin and soft tissues over an open sternum reduces the risk of sternal wound infection in these critically ill cardiac surgery patients. See Article page 77. Of the 300,000 patients who undergo cardiac surgery each year in North America,1Abu-Omar Y. Kocher G.J. Bosco P. Barbero C. Waller D. Gudbjartsson T. et al.European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.Eur J Cardiothorac Surg. 2017; 51: 10-29Crossref PubMed Scopus (76) Google Scholar as many as 12,000 (4%) leave the operating room with an open sternum.2Bakaeen F.G. Haddad O. Ibrahim M. Pasadyn S.R. Germano E. Mok S. et al.Advances in managing the noninfected open chest after cardiac surgery: negative-pressure wound therapy.J Thorac Cardiovasc Surg. 2019; 157: 1891-1903.e9Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Delayed sternal closure (DSC) was first described in 1975 by Riahi and colleagues3Riahi M. Tomatis L.A. Schlosser R.J. Bertolozzi E. Johnston D.W. Cardiac compression due to closure of the median sternotomy in open heart surgery.Chest. 1975; 67: 113-114Crossref PubMed Scopus (68) Google Scholar to prevent “tight mediastinal syndrome,” which is hemodynamic compromise resulting from sternal closure. Other common reasons for DSC are low cardiac output syndrome (sometimes requiring central mechanical circulatory support), bleeding, arrhythmias, and myocardial edema. The relative incidences of each, as reported in 3 large observational studies of DSC, are summarized in Table 1.4Furnary A.P. Magovern J.A. Simpson K.A. Magovern G.J. Prolonged open sternotomy and delayed sternal closure after cardiac operations.Ann Thorac Surg. 1992; 54: 233-239Abstract Full Text PDF PubMed Scopus (74) Google Scholar, 5Boeken U. Assmann A. Mehdiani A. Akhyari P. Lichtenberg A. Open chest management after cardiac operations: outcome and timing of delayed sternal closure.Eur J Cardiothorac Surg. 2011; 40: 1146-1150PubMed Google Scholar, 6Christenson J.T. Maurice J. Simonet F. Velebit V. Schmuziger M. Open chest and delayed sternal closure after cardiac surgery.Eur J Cardiothorac Surg. 1996; 10: 305-311Crossref PubMed Scopus (40) Google ScholarTable 1Indications for delayed sternal closureIndicationNo. of patients%Hemodynamic instability9220Low cardiac output state26658Myocardial edema245Bleeding4610Arrhythmia337 Open table in a new tab Surgeons remain concerned that DSC increases the risk of sternal wound infection (SWI), which has a mortality of 10% to 14% if it progresses to mediastinitis.1Abu-Omar Y. Kocher G.J. Bosco P. Barbero C. Waller D. Gudbjartsson T. et al.European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.Eur J Cardiothorac Surg. 2017; 51: 10-29Crossref PubMed Scopus (76) Google Scholar The risk of SWI in patients with DSC is 2% to 5%, compared with 1% to 2% in patients with primary chest closure.5Boeken U. Assmann A. Mehdiani A. Akhyari P. Lichtenberg A. Open chest management after cardiac operations: outcome and timing of delayed sternal closure.Eur J Cardiothorac Surg. 2011; 40: 1146-1150PubMed Google Scholar Whether DSC is an independent risk factor for SWI is unclear, because patients requiring DSC are critically ill and have multiple risk factors for sternal complications. Surgical technique and prophylactic antibiotic regimen may affect infection risk in patients with DSC. A widely used technique is to stent open the sternal bone with syringes and cover the wound with an Esmarch patch and an Ioban antimicrobial drape (3M, St Paul, Minn), although there are several variations. Antibiotic use in DSC varies from standard surgical prophylaxis for the first 48 hours to broad-spectrum antibiotics for several days after sternal closure.7Eckardt J.L. Wanek M.R. Udeh C.I. Neuner E.A. Fraser T.G. Attia T. et al.Evaluation of prophylactic antibiotic use for delayed sternal closure after cardiothoracic operation.Ann Thorac Surg. 2018; 105: 1365-1369Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In this issue of the Journal, Balasubramanian and Bhama8Balasubramanian V. Bhama J.K. Technique for “open sternal” chest closure in patients with assist devices and transplant recipients..J Thorac Cardiovasc Surg Tech. 2020; 2: 77-79Scopus (2) Google Scholar describe a technique for DSC in which the subcutaneous tissues and skin are closed, while the sternal bone is bridged open with an orthopedic plate. Balasubramanian and Bhama8Balasubramanian V. Bhama J.K. Technique for “open sternal” chest closure in patients with assist devices and transplant recipients..J Thorac Cardiovasc Surg Tech. 2020; 2: 77-79Scopus (2) Google Scholar propose that creating a biologic tissue barrier over the mediastinum provides superior immune protection to an Esmarch and Ioban closure. In their 29-patient series, there were no cases of sternal wound or mediastinal infection. A similar approach to DSC was published in The Journal of Thoracic and Cardiovascular Surgery in 2014, with similarly small sample size and low infection rates.9Rajakaruna C. Rodriguez G.M. Rajbanshi B.G. Ziganshin B.A. Elefteriades J.A. Novel technique for delayed sternal closure: soft tissue approximation with substernal bridge.J Thorac Cardiovasc Surg. 2014; 148: 2427-2429Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Balasubramanian and Bhama8Balasubramanian V. Bhama J.K. Technique for “open sternal” chest closure in patients with assist devices and transplant recipients..J Thorac Cardiovasc Surg Tech. 2020; 2: 77-79Scopus (2) Google Scholar demonstrate that this approach to DSC is feasible and safe, but the impact on clinical outcomes remains unclear. The sample size is small, and there is no comparison group. The theory that infection risk is reduced with a biologic tissue barrier is plausible, but it remains unsubstantiated by this series or previous literature. A recent randomized trial reported reduced SWI rates with the application of a negative-pressure dressing to an open sternum. Bakaeen and colleagues2Bakaeen F.G. Haddad O. Ibrahim M. Pasadyn S.R. Germano E. Mok S. et al.Advances in managing the noninfected open chest after cardiac surgery: negative-pressure wound therapy.J Thorac Cardiovasc Surg. 2019; 157: 1891-1903.e9Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar randomly assigned 452 patients to standard DSC or negative pressure dressing. They reported SWI rates of 5% in the control group but only 2% in the intervention group, thus reducing the risk of SWI to match that of patients with primary sternal closure.2Bakaeen F.G. Haddad O. Ibrahim M. Pasadyn S.R. Germano E. Mok S. et al.Advances in managing the noninfected open chest after cardiac surgery: negative-pressure wound therapy.J Thorac Cardiovasc Surg. 2019; 157: 1891-1903.e9Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar A randomized trial should be performed for the technique described by Balasubramanian and Bhama8Balasubramanian V. Bhama J.K. Technique for “open sternal” chest closure in patients with assist devices and transplant recipients..J Thorac Cardiovasc Surg Tech. 2020; 2: 77-79Scopus (2) Google Scholar to clarify whether a biologic barrier provides superior protection from SWI. Choice and duration of antibiotics should also be studied in a randomized fashion. Patients requiring DSC are at high risk of surgical complications, and clarifying the safest methods for DSC through randomized trials may significantly affect outcomes. Technique for “open sternal” chest closure in patients with assist devices and transplant recipientsJTCVS TechniquesVol. 2PreviewSelection criteria in both cardiac transplantation and left ventricular assist device (LVAD) placement are expanding, leaving patients at risk for problems that require the sternum to be left open after surgery, such as coagulopathy or right ventricular dysfunction. Standard approaches for keeping the sternum open rely on plastic syringe struts to spread the sternum and a nonbiological barrier (ie, esmarch). A technique is described to achieve sternal separation while maintaining a biological barrier, which has been used selectively for delayed sternal closure (Video 1). Full-Text PDF Open Access

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