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| Identifying Patients at Particular Risk of Injury At Repeat Sternotomy: Analysis of over 2500 Cardiac Reoperations |
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Chan B. Park, Rakesh M. Suri, Harold M. Burkhart, Kevin L. Greason, Joseph A. Dearani, Hartzell V. Schaff, Thoralf Sundt Mayo Clinic, Rochester, MN Objective: Reoperative sternotomy is an increasingly common clinical challenge. A variety of protective strategies have been proposed, however it remains unclear in whom such strategies are warranted. Methods: Using our STS database, we identified adults undergoing repeat median sternotomy for routine cardiac surgery between 1/1/1996 and 12/31/2007 excluding transplants, ventricular assist device implants, and procedures for congenital defect. All operative notes and perioperative outcomes were reviewed. Results: Of 2555 patients, 1537 (60%) had undergone prior CABG, 700 (27%) mitral valve surgery (MVR), and 643 (25%) aortic valve surgery (AVR); 61 patients (2%) had prior mediastinal radiation, and 424 (17%) >1 prior sternotomy. There were 267 injuries in 231 (9.0%) patients. Of 87 (33%) injuries during sternal re-entry, 21 (24%) were to saphenous vein bypass grafts (SVG) or ITA, 20 (23%) to the innominate vein, 17 (20%) to the right ventricle (RV), and 17 (20%) to the aorta. Injury was more common, however, during pre-pump dissection (n=135), of which 29 (21%) were to SVG, 28 (21%) to ITA, 15 (11%) to the innominate vein and 15 (11%) to the aorta. Patients with injury had a higher hospital mortality (18.6% vs 6.5%, p<0.001), particularly when the injury occurred during sternal re-entry (2.4% survivors vs. 9.8% mortalities, p<0.001) compared with injury during dissection (4.3% vs 10.3%, p<0.001), however only injury to the RV was a predictor of hospital death (p<0.001). The mortality rate associated with injury to the RV was 35% (11/31), aorta 21% (7/34), innominate vein 18% (7/38), SVG 18% (8/45) and ITA 17% (7/41). Injuries were more common after prior CABG (70% with injury vs 59% without, p=0.0012) but not prior AVR, MVR or aortic surgery. Injury was also more common when the current operation was AVR (51% with injury vs 44% without, p= 0.04) or aortic surgery (16% vs 10%, p=0.004). By multivariate analysis, however, only prior radiation (OR 4.3), and increased number of prior median sternotomies (OR1.6) were risk factors for injury. Institution of CPB prior to sternotomy was used in 40 patients did not assure prevention of injury (p=0.44). Conclusion: Patients with prior radiation and >1 prior sternotomy are at increased risk of complications during sternal re-entry and accordingly warrant consideration for protective strategies, as may patients with prior CABG. Given the association between RV injury and death, strategies to prevent this complication are particularly important. 
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Copyright © 2012 American Association for Thoracic Surgery
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.