Staged chest closure in pediatric cardiac surgery preventing typical and atypical cardiac tamponade

Abstract

Chest closure after cardiac surgery occasionally results in cardiaccompression leading to circulatory failure. In shunt-dependent circulation,the arterial oxygen saturation may decrease significantly due to theincrease in pulmonary vascular resistance caused by chest closure.Temporary patch implantation with delayed sternal closure facilitatescirculatory and/or pulmonary stabilization (temporary chest wall patchplasty, TCWPP). Between July 1986 and June 1991, 42 patients underwentstaged chest closure (TCWPP) after open heart surgery for congenitallesions (4.9% of 854 patients). TCWPP was performed when either primaryhemodynamic deterioration or an increase in cyanosis (palliative proceduresonly) followed by hemodynamic deterioration occurred during attempted orshortly after sternal closure. Overall mortality was 40.4% (17/42). It was32.3% (11/34) when the patch was inserted primarily at the end of theoperation. If the patch was inserted emergently 4-24 h postoperatively,mortality was 75% (6/8). Definite chest closure was performed from 4 h to 6days (mean 72 h) postoperatively. In 2 patients closure had to be performedemergently (single ventricles); 7 patients died before chest closure. Onemediastinal microbiology examination was positive. Deep sternal infectionnecessitating operative revision occurred in one other patient. Inconclusion, TCWPP may considerably lower mortality of the illest patientsafter surgery for complex congenital heart disease. A timely decision as tothe performance of staged chest closure is mandatory. This procedure rarelycauses infection. We now apply this technique liberally, bycardio-mediastinal size judgement in over 30% of our TCWPP candidates evenwithout a prior trial of primary closure.