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J Thorac Cardiovasc Surg 1995;109:1262-1263
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Primary elective open sternum with only Steri-Drape film coverage after cardiac operations in pediatric patients

Department of Cardiothoracic Surgery
UCSF
San Francisco, CA 94143-0118

To the Editor:

Clear and objective evidence exists that pressure of paracardiac structures on the heart can result in a constraining effect on diastolic ventricular filling. ¹ Conversely, relief of the constricting effect results in increased cardiac index and stroke work index, attributable to the Frank-Starling response to increased ventricular preload. ¹ Delayed sternal closure to achieve the latter objective after cardiac operations in pediatric patients has been reported. ^2-8

A recent article by Hakimi and colleagues ⁸ compared the technique of primary open sternum coupled with delayed sternal closure with the use of primary sternal closure in neonates after cardiac operations. The authors mentioned that the techniques for primary elective open sternum with delayed sternal closure can be classified into three broad categories: (1) skin closure with or without sternal stenting, (2) patch closure of the incision with or without sternal stenting, and (3) mediastinal packing. As proponents of the latter technique, Furnary and colleagues, ⁹ in adult patients, applied sterile laparotomy dressings in the mediastinum and covered the dressings with Steri-Drape plastic film (3M Company, St. Paul, Minn.).

I want to report a modification of the latter technique, namely, covering of the sternotomy wound with Steri-Drape film only. In cases of severe edema of the heart or paracardiac structures, a sternal retractor is left in place. Continuous irrigation of the mediastinum with povidone-iodine (Betadine; Purdue Frederick Company, Norwalk, Conn.) or bacitracin can be performed with substernal irrigation catheters and mediastinal drainage tubes. In case of intractable bleeding, the pericardial space and mediastinum initially can be packed with sterile gauzes or laparotomy pads, which can be removed later as the bleeding subsides. I have applied this technique in seven neonates and infants with severe cardiac edema who had undergone repair of complex congenital cardiac lesions. Delayed closure of the sternum was successfully performed after 2 to 5 days. All patients survived and none had mediastinitis or wound infection.

The main advantages of this technique are as follows: (1) The translucent Steri-Drape film allows continuous assessment of size and functional recovery of the heart; accordingly, it allows secondary sternal closure in a timely fashion; (2) maximal expansion of the pericardial and mediastinal space is obtained by leaving the sternal retractor in place; this cannot be achieved consistently with a technique that involves skin closure or even patch closure; and (3) ease of performance. The Steri-Drape film can be replaced under sterile conditions in the intensive care unit as needed.

12/8/57998

References

1. Daughters GT, Frist WH, Alderman EL, Derby GC, Ingels NB Jr, Miller DC. Effects of the pericardium on left ventricular diastolic filling and systolic performance early after cardiac operations. J THORAC CARDIOVASC SURG 1992;104:1084-91.[Abstract]
   
2. Bex JP, de Riberolles C, Lecompte Y, et al. Compression cardiaque lors de la fermeture du sternum apres correction de cardiopathies congenitales complexes. Ann Chir 1980;34:198-200.[Medline]
   
3. Björk VO, Papaconstantinou C. Delayed sternal closure following cardiac operation. Scand J THORAC CARDIOVASC SURG 1982;16:275-7.[Medline]
   
4. Shore DF, Capuani A, Lincoln C. Atypical tamponade after cardiac operation in infants and children. J THORAC CARDIOVASC SURG 1982;83:449-52.[Abstract]
   
5. Fanning WJ, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg 1987;44:169-72.[Abstract]
   
6. Odim JNK, Tchervenkov CI, Dobell ARC. Delayed sternal closure: a lifesaving maneuver after early operation for complex congenital heart disease in the neonate. J THORAC CARDIOVASC SURG 1989;98:413-6.[Abstract]
   
7. Baumgart D, Herbon G, Borowski A, de Vivie ER. Primary closure of median sternotomy with interposition of hydroxyapatite blocks. Eur J Cardiothorac Surg 1991;5:383-5.[Abstract]
   
8. Hakimi M, Walters HL III, Pinsky WW, Gallagher MJ, Lyons JM. Delayed sternal closure after neonatal cardiac operations. J THORAC CARDIOVASC SURG 1994;107:925-33.[Abstract/Free Full Text]
   
9. Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992;54:233-9.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques A. M. van Son Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M.