PROLONGED OPEN STERNOTOMY AFTER PEDIATRIC OPEN-HEART OPERATION - EXPERIENCE WITH 113 PATIENTS

Between April 1990 and November 1993, 1,252 open heart operations were performed in infants and children with congenital heart defects. Prol onged open sternotomy was used in 113 patients (9%) in 10 surgical cat egories. Thirty-six of these children (32%) were infants and 43 (38%) were newborns. Twenty-four patients (21%) had undergone operation prev iously; 3 newborns had been treated with extracorporeal membrane oxyge nation before the operation. The patients were grouped according to in dications for prolonged open sternotomy as follows: group I, 31 patien ts with squeezed (large) heart syndrome (1 death); group II, 14 patien ts with hemodynamic instability after sternal approximation (2 deaths/ 14.2%); group III, 35 patients with low output state after bypass (17 deaths/48.5%); group IV, 21 patients with extracorporeal circulatory a ssist devices (15 deaths/71.4%); group V, 3 patients with severe arrhy thmias (no deaths); and group VI, 9 patients with atypical tamponade t hat necessitated reopening the sternum in the intensive care unit (6 d eaths/66.6%). Overall mortality was 36.2% (41 patients). Four group IV patients were weaned successfully from extracorporeal membrane oxygen ation and heart transplantation was performed successfully on two othe rs. All but one of the deaths occurred before delayed sternal closure. After hemodynamic stabilization was achieved, the sternum was closed in all 72 surviving patients with absorbable sutures (in 86% within th e first 6 days after operation). In 50 patients (69% of survivors) per icardial substitution with a polytetrafluoroethylene membrane was perf ormed. One newborn with mediastinal infection after extracorporeal mem brane oxygenation was treated successfully with retrosternal drain and suction lavage. Prolonged open sternotomy is an effective method in i nfants and children with severe but temporary hemodynamic instability after open heart operation. The need for circulatory assist devices, t he development of low cardiac output syndrome after bypass, and the ne cessity of reopening the sternum in the intensive care unit were high risk factors. Using absorbable sutures for delayed sternal closure and pericardial substitution with a polytetrafluoroethylene membrane did not increase the risk of mediastinal infection significantly.