Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC 27715, USA.
J Thorac Cardiovasc Surg. 2010 May;139(5):1205-10. doi: 10.1016/j.jtcvs.2009.11.029. Epub 2010 Feb 18.
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.
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.
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).
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.
一期姑息手术后，究竟是早期还是延迟关胸更具优势，目前仍存在争议。我们描述了一期姑息手术后延迟关胸的中心差异及其相关结局。
纳入 2000 年至 2007 年期间行一期姑息手术治疗左心发育不良综合征患者，来自胸外科医师学会先天性数据库。我们考察了中心间延迟关胸的差异，并比较了低（<25%）、中（26%-74%）、高（>75%）使用延迟关胸的中心的院内死亡率、住院时间延长（住院时间>6 周）和术后感染，调整了患者和中心因素。
共纳入 1283 例患者（45 个中心）。手术时的中位年龄为 6 天（四分位距，4-9 天），手术时的中位体重为 3.2kg（四分位距，2.8-3.5kg）；59%为男性。74%的患者采用了延迟关胸（范围，3%-100%/中心）。高（n=23）和中（n=17）延迟关胸使用率中心与低（n=5）延迟关胸使用率中心相比，有更长住院时间和感染的比例更大，且校正后院内死亡率有增加的趋势。多变量分析显示死亡率无差异。高和中延迟关胸使用率中心的住院时间延长（比值比，2.83；95%置信区间，1.46-5.47；P=0.002 和比值比，2.23；置信区间，1.17-4.26；P=0.02），感染更多（比值比，2.34；置信区间，1.20-4.57；P=0.01 和比值比，2.37；置信区间，1.36-4.16；P=0.003）。
一期姑息手术后，延迟关胸的应用差异很大。这些观察性数据表明，更频繁地使用延迟关胸与更长的住院时间和更高的术后感染率相关。需要进一步评估延迟关胸在这些复杂婴儿管理中的风险和获益。
