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Ann Thorac Surg 1998;66:1575-1578
© 1998 The Society of Thoracic Surgeons

Risks of repeat sternotomy in pediatric cardiac operations

^a Division of Cardiovascular and Thoracic Surgery, British Columbia’s Children’s Hospital, Vancouver, British Columbia, Canada

Accepted for publication May 22, 1998.

Address reprint requests to Dr LeBlanc, British Columbia’s Children’s Hospital, Suite 3G63, 4480 Oak St., Vancouver, BC, Canada V6H 3V4
e-mail: (jleblanc{at}dowco.com)

	Abstract

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Background. Repeat sternotomy has been associated with increased perioperative risks.

Methods. We reviewed 165 patients undergoing 192 repeat sternotomies between January 1985 and January 1997 (group 1) and a control group of 184 patients (group 2). The operations in group 1 were valve procedures in 94 patients, Fontan procedure in 46, ventricular septal defect closure in 10, pulmonary arterioplasty in 17, and others in 25; in group 2 ventricular or atrial septal defect closure in 120 patients, tetralogy of Fallot repair in 26, valve procedures in 16, bidirectional Glenn anastomosis in 7, repair of transposition of the great arteries in 7, pulmonary arterioplasty in 4, and others in 4.

Results. The hospital mortality was 2.6% in group 1 and 3.8% in group 2. Cardiac laceration occurred in 10 of 192 patients (5.2%), requiring emergent femorofemoral bypass in 6 patients. Two patients sustained an air embolism that was successfully treated with a hyperbaric chamber. Median total blood loss and requirements were not significantly different between the two groups. The length of stay in the intensive care unit and in the hospital were 4 days (range, 1 to 80 days) and 11 days (range, 1 to 135 days) in group 1, and 2 days (range, 1 to 87 days) and 7 days (range, 1 to 131 days) in group 2 (p < 0.02 and p < 0.002, respectively). The rate of complications was not significantly different in group 1 versus group 2. Overall survival was 97% (group 1) and 95% (group 2) at 120 months’ follow-up (not significant).

Conclusions. With careful surgical technique and judicious use of femorofemoral bypass, the risk of repeat sternotomy is minimized.

	Introduction

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With advances in pediatric cardiac surgery, staged procedures and bioprosthetic conduits to repair complex forms of congenital heart disease are not only used more frequently, but also at a younger age. The survival has markedly improved in the last 15 years. Therefore, an increasing number of patients will require repeat sternotomy during childhood. Repeat operations are attended by specific technical problems with increased perioperative mortality and morbidity in adults [1, 2]; however, information in the pediatric population is scarce.

This study reviews our experience with a pediatric cardiac population undergoing repeat sternotomy for residual defects or staged repairs, assessing perioperative mortality and morbidity in comparison to a control group.

	Material and methods

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Patients
Between January 1985 and January 1997, group 1 (165 patients) underwent 192 repeat sternotomies for residual cardiac defects or staged repairs. There were 101 boys (61%) and 64 girls (39%). Primary diagnoses are summarized in Table 1. The initial surgical procedure was a bidirectional Glenn in 40 patients, ventricular septal defect closure in 34, tetralogy of Fallot repair in 29, valve procedure in 29, repair of transposition of the great arteries in 10, pulmonary arterioplasty in 15, and miscellaneous in 8. The median age and weight at initial operation were 12 months (range, 0.1 to 228 months) and 8.3 kg (range, 2.2 to 61.4 kg), respectively. Reoperations included valve procedure in 76, Fontan procedure in 45, pulmonary arterioplasty in 17, ventricular septal defect closure in 10 (5 residual and 5 previously unrepaired), and miscellaneous in 17. The median age and weight at second operation were 56.5 months (range, 3 to 228 months) and 16.3 kg (range, 4.1 to 94.5 kg), respectively. Twenty-five patients underwent a third operation including valve procedure in 17, Fontan procedure in 1, and miscellaneous in 7; 2 patients underwent a fourth operation, for a total of 192 reoperations.

Surgical procedures
Patients having the initial operation in group 1 and all patients in group 2 underwent operations with moderate hypothermia and cardioplegic arrest. Only repair of atrial septal defects was done under normothermia. Deep hypothermia and circulatory arrest was used only in repair of total anomalous pulmonary venous return and for complex pulmonary arterioplasty. Crystalloid cardioplegia was used until 1991 and replaced by blood cardioplegia thereafter. All operations were done through a sternotomy approach with cannulation of both venae cavae and the ascending aorta.

Elective femorofemoral bypass before repeat sternotomy was used in 25 patients of group 1. Our criteria for femorofemoral bypass were conduits located directly underneath the sternum, lack of retrosternal space, and surgeon’s preference. The retrosternal space was always assessed by a lateral chest roentgenogram.

Statistical analysis
The median and range were calculated for all descriptive variables. The Wilcoxon rank-sum test was used to test for equality of the median values. Actuarial data for survival was analyzed using Kaplan-Meier estimates. Comparison of the survival curves was made using a log-rank test. All statistical analyses were completed with SAS statistical software (Cary, NC).

	Results

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Hospital mortality
Overall hospital mortality was 2.6% (5 of 192) in group 1 and 3.8% (7 of 184) in group 2 (not significant). The most common cause of death was low output syndrome secondary to ventricular dysfunction.

Early morbidity
Cardiac lacerations at repeat sternotomy occurred in 10 of 192 operations (5.2%), requiring emergent femorofemoral bypass in 6. None of these patients sustained severe hypotension or cardiac arrest. In 4 patients bleeding could be controlled without institution of femorofemoral bypass. The location of the laceration was the bioprosthetic conduit in 5 patients, the right ventricle in 2, the right atrium in 2, and the aorta in 1.

Severe air embolism was suspected in 2 patients with univentricular hearts because of laceration of the right atrium allowing air entry to the common atrial chamber. The operation was aborted and both patients were immediately transported to a nearby facility for hyperbaric treatment, which lasted 6 hours at 3 atmospheres. During this period the patients were supervised by our intensive care specialist and a nurse. Neither of these patients sustained cerebral damage as confirmed by clinical examination and a head computed tomographic scan. They had successful surgical repair 3 days later.

Elective femorofemoral bypass was used in 25 repeat sternotomy procedures, 14 of which were first resternotomies, and 11 were second resternotomies. Two patients in this group sustained a cardiac laceration despite the use of cardiopulmonary bypass. The median age of these 25 patients was 139 months (range, 5 to 219 months), whereas the median age of the 10 patients who sustained cardiac lacerations was 63 months (range, 42 to 228 months). In this group with elective and urgent femoro-femoral bypass, no patient had a measurable retrosternal space and 18 patients had previous homograft conduit implantation. The median age of the patients who did not undergo femorofemoral bypass was 48 months (range, 3 to 212 months). Although the criteria for femorofemoral bypass are currently more rigidly adhered to, its use was infrequent at the beginning of the study period and was left to the surgeon’s preference.

We compared group 1 (repeat sternotomy) with its own initial operation and then group 1 (repeat sternotomy) with group 2 (control), analyzing multiple parameters.

Group 1
The perioperative variables of group 1 at initial operation and reoperation, including bypass and cross-clamp time, total blood loss in 24 hours, blood requirement, intensive care unit length of stay (LOS) and hospital LOS, are summarized in Table 2. There was no statistical difference except for blood requirement (p < 0.0001). The most common postoperative complications at the initial operation and reoperation are summarized in Table 3. There was no statistical difference.

Groups 1 and 2
When group 1 (repeat sternotomy) was compared with group 2 (control), the median bypass time and cross-clamp time were 104 minutes (range, 24 to 281 minutes) and 58 minutes (range, 11 to 197 minutes) in group 1, and 77 minutes (range, 17 to 258 minutes) and 48 minutes (range, 8 to 133 minutes) in group 2 (p < 0.0001). The median blood loss and blood requirement in group 1 and group 2 were not statistically different. The LOS in the intensive care unit and in the hospital were 4 days (range, 1 to 80 days) and 11 days (range, 1 to 135 days) in group 1, and 2 days (range, 1 to 87 days) and 7 days (range, 1 to 131 days) in group 2 (p < 0.02 and p < 0.002, respectively).

Follow-up
Group 1 survivors were followed up for a median of 84 months (range, 4 to 280 months) and group 2 survivors for a median of 50.5 months (range, 0.1 to 131 months). In group 1 there were three late sudden deaths at 6, 14, and 18 months, all caused by presumed arrhythmia. In group 2 there were two late deaths at 1.5 months caused by pericardial tamponade and at 11 months caused by superior vena cava thrombosis. Overall survival by Kaplan-Meier analysis was 97% (group 1) and 95% (group 2) at 120 months (not significant) (Fig 1).

View larger version (17K): [in this window] [in a new window]   Fig 1. Long-term survival excluding perioperative mortality.

	Comment

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Although some adult literature has shown a trend toward a higher risk at reoperation [4, 5], our mortality in the repeat sternotomy group compared with the control group shows no statistical difference (2.6% versus 3.8%). The higher risk of reoperation in the adult population has been associated with advanced New York Heart Association class. The same parallel cannot be established with our group. Most of our patients were not reoperated on on the basis of deteriorating cardiac function, but rather because of conduit or valve obstruction from somatic outgrowth and planned staging in the complex heart defect group. Only 3 patients could have been classified as New York Heart Association class III in the conduit or valve obstruction group and underwent operation emergently. The remainder of our patients underwent operation on an elective basis.

Perioperative morbidity can be detrimental and recovery from reoperation may be prolonged. The incidence of postoperative complications in group 1 and group 2 was similar and does not support the notion of increased perioperative morbidity after repeat sternotomy. Nevertheless the LOS in the intensive care unit and in the hospital were significantly longer in group 1 than in group 2 (p < 0.02 and p < 0.002, respectively). We would argue that this increased LOS is related to the type of operation as 45 patients underwent a second-stage Fontan procedure with a median LOS of 22 days (range, 9 to 125 days). This group of patients is well-known for their prolonged chest tube drainage postoperatively related to their cardiac physiology and not to the risk of repeat sternotomy itself.

Cardiac structures were entered 10 times at repeat sternotomy requiring emergent institution of femorofemoral bypass in 6 patients. Elective femorofemoral bypass was used in 25 patients. All lacerations were controlled and were not detrimental to the patient’s outcome. We established that a calcified conduit behind the sternum and lack of retrosternal space were the main risk factors. A lateral chest roentgenogram is routinely done to assess the retrosternal space and thus helped to determine the need for femorofemoral bypass. The median age of the patients who did and did not undergo femorofemoral bypass was 139 months and 48 months, respectively. It is obvious that the majority of our patients are young children and they fall in a different group. We make every effort to defer cannulating the femoral vessels as it is difficult to obtain proper cardiopulmonary bypass flow and the vessels can be severed more easily. Two children underwent cannulation of their iliac vessels because of their complexity, but we tried to avoid this approach as a laparotomy adds to the risk of the procedure.

Blood product strategies have changed over the years. It is interesting to note that blood loss and blood requirements between the repeat sternotomy and the control group were not statistically different. Tranexamic acid is given to all repeat sternotomy patients before operation and is added to the prime. We are unable to explain the statistical difference in blood loss in the subgroups of group 1. However the initial operation was done at a younger age and was undeniably more complex in many patients, increasing the risk of postoperative coagulopathy.

The survival by Kaplan-Meir analysis is similar in both groups at 120 months. A longer follow-up is required to determine long-term outcome as the combined parameters of repeat sternotomy, myocardial protection, and ventricular dysfunction may express themselves as definite risk factors.

A significant limitation of our study relates to the fact that repeat sternotomy is only one parameter of outcome. Clinical results are more likely to depend on the complexity of the primary diagnosis and the procedure as well as the quality of the surgical repair. The longer intensive care unit and hospital LOS in group 1 exemplifies this fundamental problem.

In summary, our study shows that repeat sternotomy carries very minimal added risk. However, cardiac laceration is a definite possibility and can be minimized by assessment of the retrosternal space on lateral chest roentgenogram, careful surgical technique, and judicious use of elective femorofemoral bypass.

	References

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1. Pansini S., Ottino G., Forsennati P.G., et al. Reoperations on heart valve prostheses: an analysis of operative risks and late results. Ann Thorac Surg 1990;50:590-596.[Abstract]
2. Cohn L.H., Aranki S.F., Rizzo R.J., et al. Decrease in operative risk of reoperative valve surgery. Ann Thorac Surg 1993;56:15-21.[Abstract]
3. Piehler J.M., Blackstone E.H., Bailey K.R., et al. Reoperation on prosthetic heart valves: patient-specific estimates of in-hospital events. J Thorac Cardiovasc Surg 1995;109:30-48.[Abstract/Free Full Text]
4. He G.W., Acuff T.E., Ryan W.H., He Y.H., Mack M.J. Determinants of operative mortality in reoperative coronary artery bypass grafting. J Thorac Cardiovasc Surg 1995;110:971-978.[Abstract/Free Full Text]
5. Biglioli P., DiMatteo S., Parolari A., Antona C., Arena V., Sala A. Reoperative cardiac valve surgery: a multivariable analysis of risk factors. Cardiovasc Surg 1994;2:216-222.[Medline]

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