Two-stage sternal closure after repair of congenital heart disease in neonates.

Closure of the longitudinal sternal incision can lead to unacceptable impairment of the haemodynamic state after prolonged operation for complex congenital heart disease associated with decreased cardiac function which is caused by cardiac dilatation. Between 1981 and 1991, a two-stage sternal closure was used in 21 neonates with dilatation of the heart and low cardiac output after correction of congenital heart disease. The mean age at operation was 14 (range 4-30) days. In 15 patients (group 1), primary closure of the sternum was considered impossible in the operating room; in the remaining six (group 2), the sternum was reopened on the day of operation or on the first or second day after repair. Three of these newborn infants had a total anomalous pulmonary venous connection and 18 a simple transposition of the great arteries. In all patients, temporary closure of the thorax with a dura mater patch was performed. The patch was usually removed on day 4 after operation in the intensive care unit and followed by uncomplicated routine chest closure. There were no problems with mediastinitis, wound infection, osteomyelitis or instability of the sternum. Subsequent deformity of the thorax was not observed. Some 11 of 15 children (73%) of group 1 and four of six (66%) of group 2 survived. Leaving the sternum open resulted in a significant improvement in the haemodynamics in all patients. The technique of two-stage closure of the sternum is very effective after lengthy corrective operation in children with congenital malformations of the heart who require long periods of perfusion or ischaemia.