A policy of elective delayed sternal closure does not improve the outcome after arterial switch

A Systematic Review of Antibiotic Prophylaxis for Delayed Sternal Closure in Children

Antibiotic prophylaxis following delayed sternal closure in pediatric cardiac surgery is not standardized. We systematically reviewed relevant literature published between 1990 and 2019 to aid future trial design. Patient characteristics, antimicrobial prophylaxis regimens, and postoperative incidence of infection were collected. Twenty-eight studies described 36 different regimens in over 3,000 patients. There were 11 single-drug regimens and 25 multidrug regimens. Cefazolin-only was the most common regimen (9/36, 25%). The overall incidence of surgical site infection was 7.5% (217/2,910 patients) and bloodstream infection was 7.4% (123/1,667 patients). In the 2010s, multidrug regimens were associated with a significantly lower incidence of both surgical site infections (4.6% vs. 20%, P < .001) and bloodstream infections (6.0% vs. 50%, P < .001) compared to single-drug regimens.

Transposition of the Great Arteries and Common Variants

OBJECTIVES

The objectives of this review are to discuss the physiology, perioperative management, surgical correction, and outcomes of infants with transposition of the great arteries and common variants undergoing the arterial switch operation.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

The widespread adoption of the arterial switch operation for transposition of great arteries has been one of the more gratifying advances in pediatric cardiovascular care, and represents the simultaneous improvements in diagnostics, surgical and bypass techniques, anesthesia in the neonate, improvements in intensive care technology, nursing strategies, and system-wide care delivery. Many of the strategies adopted for the neonate with transposition of the great arteries have been translated to neonatal care for other congenital heart lesions. Continued work is necessary to investigate the effects of perioperative care on long-term neurodevelopmental outcomes, as well as collaboration between centers to spread "best practices" for outcome, cost, and morbidity reduction.

D-transposition of the great arteries: the current era of the arterial switch operation

This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early- and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO.

Indications and risks of delayed sternal closure after open heart surgery in neonates and early infants

BACKGROUND

Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years.

METHODS

The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days).

RESULTS

Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively (P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group (P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively).

CONCLUSION

Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.

Center variation and outcomes associated with delayed sternal closure after stage 1 palliation for hypoplastic left heart syndrome

OBJECTIVE

There is debate whether primary or delayed sternal closure is the best strategy after stage 1 palliation for hypoplastic left heart syndrome. We describe center variation in delayed sternal closure after stage 1 palliation and associated outcomes.

METHODS

Society of Thoracic Surgeons Congenital Database participants performing stage 1 palliation for hypoplastic left heart syndrome from 2000 to 2007 were included. We examined center variation in delayed sternal closure and compared in-hospital mortality, prolonged length of stay (length of stay > 6 weeks), and postoperative infection in centers with low (< or = 25% of cases), middle (26%-74% of cases), and high (> or = 75% of cases) delayed sternal closure use, adjusting for patient and center factors.

RESULTS

There were 1283 patients (45 centers) included. Median age at surgery was 6 days (interquartile range, 4-9 days), and median weight at surgery was 3.2 kg (interquartile range, 2.8-3.5 kg); 59% were male. Delayed sternal closure was used in 74% of cases (range, 3%-100% of cases/center). In centers with high (n = 23) and middle (n = 17) versus low (n = 5) delayed sternal closure use, there was a greater proportion of patients with prolonged length of stay and infection, and a trend toward increased in-hospital mortality in unadjusted analysis. In multivariable analysis, there was no difference in mortality. Centers with high and middle delayed sternal closure use had prolonged length of stay (odds ratio, 2.83; 95% confidence interval, 1.46-5.47; P = .002 and odds ratio, 2.23; confidence interval, 1.17-4.26; P = .02, respectively) and more infection (odds ratio, 2.34; confidence interval, 1.20-4.57; P = .01 and odds ratio, 2.37; confidence interval, 1.36-4.16; P = .003, respectively).

CONCLUSION

Use of delayed sternal closure after stage 1 palliation varies widely. These observational data suggest that more frequent use of delayed sternal closure is associated with longer length of stay and higher postoperative infection rates. Further evaluation of the risks and benefits of delayed sternal closure in the management of these complex infants is necessary.

Risk factors for mediastinitis following median sternotomy in children

BACKGROUND

Mediastinitis is a devastating complication of pediatric cardiothoracic surgery. However, risk factors for the development of mediastinitis are poorly characterized. The objective of this study was to identify risk factors for mediastinitis in a cohort of children undergoing cardiothoracic surgery at a tertiary care children's hospital.

METHODS

This case-control study included patients who underwent median sternotomy between January 1, 1995 and December 31, 2003. Univariate analyses, logistic regression, and multinomial regression were performed to determine the association between potential risk factors and the development of mediastinitis.

RESULTS

Forty-three patients with mediastinitis and 184 patients without mediastinitis were included. One hundred and twelve (49%) patients were female. The median patient age was 128 days (interquartile range: 7 days-2.0 years). A known or possible genetic syndrome was present in 53 (24%) patients. The following factors were associated with the development of mediastinitis: presence of a known or possible genetic syndrome (adjusted odds ratio, OR: 4.5; 95% confidence interval, CI: 1.8-11.4); American Society of Anesthesiologists score >3 (adjusted OR: 3.4; 95% CI: 1.1-10.3); and presence of intracardiac pacing wires for >3 days (adjusted OR: 15.8; 95% CI: 2.0-127.2).

CONCLUSIONS

The presence of a known or possible genetic syndrome, American Society of Anesthesiologists score >3, and the presence of intracardiac pacing wires for >3 days were each associated with the development of mediastinitis in children after median sternotomy.

Pediatric Poststernotomy Mediastinitis

BACKGROUND

Mediastinitis results in significant morbidity in pediatric cardiac patients. It is not clear whether delayed sternal closure is a risk factor for these infections. Management of mediastinitis remains controversial.

METHODS

Cases of mediastinitis at the Stollery Children's Hospital from January 1, 1991, to June 30, 2004, were reviewed.

RESULTS

There were 29 cases of mediastinitis in 2,675 open cardiac procedures for an overall incidence of 1.1%. Infection was diagnosed 5 to 27 days after the original surgical procedure (median, 10 days). The odds ratio for infection with delayed sternal closure versus primary sternal closure was 1.88 (95% confidence interval, 0.63 to 5.60). Signs at the onset of infection included fever (86%), incisional erythema (69%), purulent drainage from the incision or pacer wire sites (83%), and wound dehiscence (23%). Debridement was followed by primary sternal closure in all but three cases in which the sternum had not been closed before debridement and rotational muscle flaps were not used. Continuous irrigation systems were used only in the first 7 patients. One patient died of mediastinitis complicated by infective endocarditis, and 2 patients died of multiorgan failure.

CONCLUSIONS

Delayed sternal closure was not a major risk factor for mediastinitis, especially if primary skin closure was used with delayed sternal closure. Excellent results were attained with debridement and primary closure of these infections.

Current expectations for newborns undergoing the arterial switch operation

BACKGROUND

The arterial switch operation (ASO) represents a remarkable success story in the surgical treatment of cyanotic congenital heart disease. This study is designed to assess recent outcomes after the ASO in babies presenting with transposition of the great arteries (TGA) and Taussig-Bing anomaly (TBA).

METHODS

One hundred twenty-five consecutive neonatal and infant ASOs were performed by 2 surgeons at Texas Children's Hospital between July 1, 1995 and October 1, 2003. Patients with TGA and TBA were offered ASO irrespective of patient size and associated cardiac malformations. Primary cardiac diagnoses included TGA with intact ventricular septum (TGA/IVS, n = 79, 63%), TGA with ventricular septal defect (TGA/VSD, n = 37, 30%), and Taussig Bing Anomaly (TBA, n = 9, 7%).

RESULTS

With complete follow-up, we observed a 30-day mortality rate of 1.6% (n = 2) with 2 late deaths (1.6%), for an overall actuarial survival rate of 96.3% at 7 years. Although there was a significant incidence of complex coronary ostial origin and branching including single coronary (n = 8, 6.4%) and intramural coronary artery (n = 8, 6.4%), this was not associated with increased operative risk. All patients are fully saturated and NYHA functional class I at latest clinic visit (0.3 to 88.4 months postoperatively). There have been no late coronary events. Of 121 survivors, 7 patients (5.8%) have required cardiovascular reoperation at an average of 15.3 +/-11.7 months postoperatively (range, 3.6 to 30.6 months) for an actuarial freedom from reoperation of 90% at 7 years.

CONCLUSIONS

Using current methodologies, the ASO can be performed safely and with a low incidence of need for reoperation on intermediate follow-up. Recent experience indicates operative survival rates approaching 100%.