Christenson J T, Maurice J, Simonet F, Velebit V, Schmuziger M
Cardiovascular Unit, Hôpital de la Tour, Geneva, Switzerland.
Eur J Cardiothorac Surg. 1996;10(5):305-11. doi: 10.1016/s1010-7940(96)80087-x.
Open chest (OC) and subsequent delayed sternal closure (DSC) has been described as a useful method in the treatment of the severely impaired heart after cardiac surgery.
Prolonged open chest was used in 142 to 3373 adult cardiac operations (4.2%) between January 1987 and December 1993. The indications were: hemodynamic compromise (121), intractable bleeding (9) and arrhythmias (12). Delayed sternal closure was carried out in 123 of 142 patients at a mean of 2.0 +/- 1.4 days (range 0.5-8 days). Open chest and DSC were used proportionally more frequently after combined cardiac surgery (28/293, 9.6%) than after coronary artery bypass grafting (CABG) alone (108/2891, 3.7%) or valve operation (6/230, 2.6%).
Ninety-seven of the 123 who had DSC (78.9%) survived and were discharged an average of 8.6 +/- 4.2 days after closure. Fourty-five patients died: 19 before DSC and 26 after this method. Mortality was related to indications for OC: when the indication was low cardiac output the mortality was 38.6%, for hemodynamic collapse on closure 0%, diffuse bleeding 33.3% and arrhythmias 27.3%. Delayed sternal closure in patients without intraaortic balloon pump support was more likely to be successful (mortality rate 4/25, 16.0% versus 35/76, 46.3%, P < 0.01). Superficial sternal wound infection occurred in 2 of 123 (1.6%) patients after DSC, mediastinitis in 1 (0.8%) and sternal dehiscence in 3 (2.4%) patients, which does not differ from a control population that had primary sternal closure. The follow-up of 97 survivors at an average of 28 +/- 4 months revealed an improvement of NYHA class by 1.4 +/- 0.4. There were 16 deaths (13 cardia-related) during the follow-up period and 3 redo CABG. One case of sternal osteomyelitis occurred without any other late sternal morbidity.
This study shows that OC with DSC is a beneficial adjunct in the treatment of postoperatively impaired cardiac function, profuse hemorrhage and persistent arrhythmias. It can be performed without increased sternal morbidity. Long-term results are also encouraging.
开胸（OC）及随后的延迟胸骨闭合（DSC）已被描述为心脏手术后治疗严重受损心脏的一种有效方法。
1987年1月至1993年12月期间，142至3373例成人心脏手术（4.2%）采用了延长开胸。适应证包括：血流动力学不稳定（121例）、顽固性出血（9例）和心律失常（12例）。142例患者中的123例平均在2.0±1.4天（范围0.5 - 8天）进行了延迟胸骨闭合。联合心脏手术后开胸和DSC的使用比例（28/293，9.6%）高于单纯冠状动脉旁路移植术（CABG）（108/2891，3.7%）或瓣膜手术（6/230，2.6%）。
123例接受DSC的患者中有97例（78.9%）存活并在闭合后平均8.6±4.2天出院。45例患者死亡：19例在DSC前死亡，26例在采用该方法后死亡。死亡率与开胸适应证相关：当适应证为低心输出量时，死亡率为38.6%，闭合时血流动力学衰竭为0%，弥漫性出血为33.3%，心律失常为27.3%。未使用主动脉内球囊泵支持的患者延迟胸骨闭合更可能成功（死亡率4/25，16.0%对35/76，46.3%，P<0.01）。DSC后123例患者中有2例（1.6%）发生浅表胸骨伤口感染，1例（0.8%）发生纵隔炎，3例（2.4%）发生胸骨裂开，这与一期胸骨闭合的对照组无差异。97例幸存者平均随访28±4个月显示纽约心脏协会（NYHA）心功能分级改善1.4±0.4级。随访期间有16例死亡（13例与心脏相关）和3例再次行CABG。发生1例胸骨骨髓炎，无其他晚期胸骨并发症。
本研究表明，OC联合DSC是治疗术后心脏功能受损、大量出血和持续性心律失常的有益辅助方法。可在不增加胸骨并发症的情况下进行。长期结果也令人鼓舞。
