Original article
Pediatric cardiac
Repeat Sternotomy in Congenital Heart Surgery: No Longer a Risk Factor

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
https://doi.org/10.1016/j.athoracsur.2008.04.044Get rights and content

Background

The risk of repeat sternotomy (RS) is often taken into account when making clinical management decisions. Current literature on RS suggests a risk of approximately 5% to 10% for major morbidity. We sought to establish the true risk of RS in a contemporary pediatric series.

Methods

All RS between October 2002 and August 2006 were analyzed (602 RS in 558 patients). Median age was 3.6 years (range, 0.1 to 45.1); weight, 14.2 kg (2.0 to 112.2). Operations performed at RS were Glenn 22% (131), Fontan 21% (129), aortic valve repair/replacement 12% (72), right ventricle-pulmonary artery conduit 11% (67), Rastelli 7% (39), heart transplant 5% (31), and other 22% (133). Forty-seven percent of patients (280) had single-ventricle physiology. Incidence of second sternotomy was 67% (406), third 28% (166), fourth 4% (24), fifth 0.8% (5), and sixth 0.2% (1). A major injury upon RS was defined as one causing hemodynamic instability requiring vasopressor support or emergent transfusion; femoral cannulation or emergent cardiopulmonary bypass; and any morbidity. A minor injury is any other injury during RS.

Results

The incidence of a major injury was not different between RS (0.3%; 2 of 602) and first-time sternotomy (0%; 0 of 1,274; p > 0.1). Incidence of a minor injury was 0.66% (4 of 602). No injury resulted in hemodynamic instability, neurologic injury, or death. Two patients (0.3%) required a nonemergent blood transfusion secondary to injury. (Nonemergent was defined as adminstration rate of less than 0.2 cc/kg/min and less than 10 cc/kg in total.) Femoral cannulation was performed in 4 of 602 RS cases (< 0.6%). Sternal wound infection was 0.5% (3 of 602); reoperation for postoperative bleeding was 1% (8 of 602). Median intensive care unit stay was 3 days (1 to 174); median hospital stay was 7 days (1 to 202). Hospital survival was 98%.

Conclusions

Repeat sternotomy can represent a negligible risk of injury and of subsequent morbidity or mortality. Therefore, the choice of management strategies for patients should not be affected by the need for RS.

Section snippets

Material and Methods

The medical records of all repeat median sternotomies (n = 602) performed at TCH from October 2002 through July 2006 were retrospectively reviewed with the approval of the Baylor Institutional Review Board, which allowed individual consent to be waived given the retrospective nature of the study. Repeat sternotomy was defined as a sternotomy requiring the use of a saw to reopen the full length of the sternum and one that was at least 1 month after the prior sternotomy.

Results

Six hundred and two consecutive RS operations were performed on 558 patients. The incidence of RS over the study period was 32% (602 of 1,876). The median age at RS was 3.6 years (0.1 to 45.1), and the median weight was 14.2 kg (2.3 to 112.2 kg). The majority of the patients (35%) were between 3 and 10 years of age (Fig 1). Thirty-nine percent of the cohort was female. Bidirectional Glenn (22% [131]) was the most commonly performed procedure at RS, followed by Fontan's procedure (21% [129], 8

Comment

Repeat sternotomy in congenital heart surgery has always been prevalent because of the pathology, staged procedures, and the nature of palliation. However, with the success of neonatal repair and other palliative operations, the incidence of RS continues to increase. This has resulted in an exponential increase in adults with severe congenital heart disease, of whom the vast majority will need several operations [1]. In fact, the number of adults with severe congenital heart disease in 2002

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