Delayed Sternal Closure vs Emergency Sternal Reopening in Adults with Congenital Heart Disease

BACKGROUND

Limited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD).

METHODS

We reviewed 159 ACHD patients undergoing cardiac surgery 1993-2023, who required DSC (open sternum at the end of operation, n=112) or ESR (sternum emergently reopened, n=47). Regression models were performed to determine factors associated with outcomes.

RESULTS

Of 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days, and 25 patients (22.3%) >4 days. The most common operations were valve (n=35, 31.2%), aortic (n=33, 29.4%), and right ventricular outflow tract procedures (n=23, 20.5%). Median time to chest closure was 2 days (interquartile range 1, 5). Apart from gender, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC≤4 days to DSC>4 days (6.8% vs 32%), as well as incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (p=0.02), DSC >4 days (p<0.001), hemodynamic indication (p=0.03), and single ventricle (p=0.02). On multivariable analysis, lower ejection fraction (p=0.04), hemodynamic indication (p=0.02), single ventricle (p=0.004), and diabetes mellitus (p=0.03) were predictors of prolonged time to chest closure. Amongst hospital survivors, there was no difference in late survival between patients undergoing DSC ≤4 days vs >4 days (p=0.48).

CONCLUSIONS

Brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.

Systemic Atrioventricular Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Vessels

BACKGROUND

Limited data exist regarding the long-term outcomes of systemic atrioventricular valve (SAVV) intervention (morphologic tricuspid valve) in congenitally corrected transposition (ccTGA).

OBJECTIVES

The goal of this study was to evaluate the mid- and long-term outcomes of SAVV surgery in ccTGA.

METHODS

We performed a retrospective review of 108 ccTGA patients undergoing SAVV surgery from 1979 to 2022. The primary outcome was a composite endpoint of mortality, cardiac transplantation, or ventricular assist device implantation. The secondary outcome was long-term systemic right ventricular ejection fraction (SVEF). Cox proportional hazard and linear regression models were used to analyze survival and late SVEF data.

RESULTS

The median age at surgery was 39.5 years (Q1-Q3: 28.8-51.0 years), and the median preoperative SVEF was 39% (Q1-Q3: 33.2%-45.0%). Intrinsic valve abnormality was the most common mechanism of SAVV regurgitation (76.9%). There was 1 early postoperative mortality (0.9%). Postoperative complete heart block occurred in 20 patients (18.5%). The actuarial 5-, 10-, and 20-year freedom from death or transplantation was 92.4%, 79.1%, and 62.9%. The 10- and 20-year freedom from valve reoperation was 100% and 93% for mechanical prosthesis compared with 56.6% and 15.7% for bioprosthesis (P < 0.0001). Predictors of postoperative mortality were age at operation (P = 0.01) and preoperative SVEF (P = 0.04). Preoperative SVEF (P < 0.001), complex ccTGA (P = 0.02), severe SAVV regurgitation (P = 0.04), and preoperative creatinine (P = 0.003) were predictors of late postoperative SVEF.

CONCLUSIONS

SAVV surgery remains a valuable option for the treatment of patients with ccTGA, with low early mortality and satisfactory long-term outcomes, particularly in those with SVEF ≥40%. Timely referral and accurate patient selection are the keys to better long-term outcomes.

Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery

BACKGROUND

Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening.

METHODS

We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed.

RESULTS

Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC.

CONCLUSIONS

PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.

Aortic Valve Replacement in the Elderly

Background—

Few data exist on long-term outcomes of elderly patients after aortic valve replacement. We evaluated latest follow-up information for patients ≥70 years of age after aortic valve replacement.

Methods and Results—

Late overall survival of 2890 consecutive patients ≥70 years of age who underwent aortic valve replacement between January 1993 and December 2007 was reviewed retrospectively, analyzed, and stratified by preoperative and intraoperative variables. Observed 5-, 10-, and 15-year late postoperative survival was lower than generally expected (68%, 34%, and 8% versus 70%, 42%, and 20%, respectively; P <0.001). Independent predictors of late death included older age, renal failure, diabetes mellitus, stroke, myocardial infarction, immunosuppression, prior coronary artery bypass grafting, implanted pacemaker, lower ejection fraction, hypertension, and New York Heart Association class III or IV. After stratification by age–comorbidity risk score, 10-year survival for the lowest-risk group (n=946 [33%]) was similar to expected survival (55% versus 55%; P =0.50), but for the highest-risk group (n=564 [20%]), survival was significantly lower than expected (9% versus 26%; P <0.001). For 229 pairs of propensity-matched patients with mechanical or biological prostheses, survival was not significantly different (67%, 40%, and 19% versus 71%, 45%, and 7% at 5, 10, and 15 years, respectively; P =0.81). Structural deterioration of bioprostheses occurred in 64 patients (2.4%).

Conclusions—

Survival of elderly patients after aortic valve replacement is influenced by age and preoperative comorbidities; 33% at lowest risk had overall survival similar to that of an age- and sex-matched general population. There was no sufficient evidence that valve type affected survival. Structural deterioration of aortic bioprostheses was rare.

Left ventricular remodeling early after correction of mitral regurgitation: maintenance of stroke volume with decreased systolic indexes

OBJECTIVE

Mitral valve repair for mitral regurgitation is followed by left ventricle adjustment to new preload and afterload. We evaluated left ventricular geometry and function immediately after mitral valve repair for degenerative prolapse.

METHODS

We prospectively studied 25 patients undergoing mitral valve repair; 15 patients undergoing a coronary artery bypass graft served as controls to determine the impact of cardiopulmonary bypass and cardioplegic arrest on left ventricular function. Intraoperative transesophageal echocardiography was conducted after sternotomy before initiation of cardiopulmonary bypass and after termination of cardiopulmonary bypass and protamine infusion. Simultaneous pulmonary catheter data ensured that the images were obtained under similar hemodynamic conditions.

RESULTS

Immediately after mitral valve repair, left ventricular fractional area change decreased significantly from 65% ± 7% to 52% ± 8% (P < .001). Left ventricular end-diastolic area decreased minimally (21.3 ± 5.3 cm(2) vs 19.4 ± 4.5 cm(2); P = .005), whereas left ventricular end-systolic area increased significantly (7.5 ± 2.3 cm(2) vs 9.3 ± 2.5 cm(2); P < .001). Notably, forward stroke volume (thermodilution) remained similar (63 ± 24 mL vs 66 ± 19 mL; P = .5). No significant difference was found in controls between pre- cardiopulmonary bypass and post-cardiopulmonary bypass fractional area change (54% ± 12% vs 57% ± 10%; P = .19), left ventricular end-diastolic area (16.6 ± 6.2 cm(2) vs 15.7 ± 5.0 cm(2); P = .32), and stroke volume (72 ± 29 mL vs 65 ± 19 mL; P = .15); they had a slight decrease in left ventricular end-systolic area (7.9 ± 4.4 cm(2) vs 6.9 ± 3.2 cm(2); P = .03).

CONCLUSIONS

Early after correction of mitral regurgitation, left ventricular fractional area change decreases significantly, primarily as the result of a larger end-systolic dimension. This may be a compensatory mechanism to prevent augmentation of forward stroke volume after mitral valve repair.