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      Delayed sternal closure does not reduce complications associated with coagulopathy and right ventricular failure after left ventricular assist device implantation

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          Abstract

          Delayed sternal closure (DSC) is occasionally adopted after implantation of left ventricular assist device (LVAD). Recent studies suggest that DSC be used for high risk group of patients with coagulopathy, hemodynamic instability or right ventricular failure. However, whether DSC is efficacious for bleeding complication or right ventricular failure is not known. This study is single center analysis of 52 patients, who underwent LVAD implantation. Of those 52 patients, 40 consecutive patients underwent DSC routinely. The sternum was left open with vacuum assist device after implantation of LVAD. Perioperative outcome of the patients who underwent routine DSC were compared with 12 patients who had immediate sternal closure (IC). Mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level of IC group and DSC group were 2.7 and 2.6, respectively. Postoperative bleeding (643 vs. 1469 ml, p < 0.001), duration of inotropic support (109 vs. 172 h, p = 0.034), and time to extubation (26 vs. 52 h, p = 0.005) were significantly increased in DSC group. Length of ICU stay (14 vs. 15 days, p = 0.234) and hospital stay (28 vs. 20 days, p = 0.145) were similar. Incidence of right ventricular failure and tamponade were similar in the two groups. Routine DSC after implantation of an LVAD did not prove to be beneficial in reducing complications associated with coagulopathy and hemodynamic instability including cardiac tamponade or right ventricular failure. We suggest that DSC be selectively applied for patients undergoing LVAD implant.

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          Bleeding complications and blood product utilization with left ventricular assist device implantation.

          Justin M Schaffer, George J. Arnaoutakis, Jeremiah G Allen … (2011)
          Bleeding complications are a major source of morbidity and reoperation after left ventricular assist device (LVAD) implantation, yet remain poorly characterized in patients receiving LVADs. We assessed bleeding complications in an institutional cohort of LVAD patients. We reviewed patients who received continuous-flow (CF) LVADs at our institution (October 2004 to May 2009). Intraoperative and postoperative transfusion requirements (packed red blood cells, fresh frozen plasma, and platelets), chest tube output, and reoperation for bleeding complications were assessed. Univariate and multivariable Cox proportional hazard analysis assessed the impact of intraoperative bleeding on mortality. A subset of our patient population underwent delayed sternal closure as opposed to primary closure and an analysis of reoperation for bleeding was undertaken stratifying patients by approach to closure. Eighty-six CF LVADs were implanted over our study period. Patients had poor preoperative cardiac function and high preoperative risk indices. Patients receiving LVADs had high intraoperative (11.6 ± 7.5 units) and postoperative (15.6 [±12.6] units in the first week) blood product requirements, as well as significant chest tube output (5,880 [±4,480] milliliters in the first week). On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of mortality. Eleven (28%) patients undergoing primary sternal closure required reoperation for bleeding, while delayed sternal closure patients generally had resolution of bleeding prior to sternal closure. The incidence of gastrointestinal bleeding was 28% at one year. On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of 30-day and one-year mortality, while chest tube output during the first postoperative 48 hours predicted 30-day but not one-year mortality. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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            Prolonged open sternotomy and delayed sternal closure after cardiac operations.

            George Magovern, Angela Simpson, Anthony Furnary (1992)
            Maintenance of an open sternotomy (OS) after a complicated cardiac operation is an adjunct in the treatment of the severely impaired heart. We hypothesized that predictors of the timing, morbidity, and prognosis of delayed sternal closure (DSC) could be determined by intensive case review. Prolonged OS was used in 107 of 6,030 adult open heart patients (1.8%) between 1987 and 1991. Indications for OS were hemodynamic instability (40), myocardial edema (18), intractable bleeding (23), relentless arrhythmias (9), and ventricular assist devices (17). Delayed sternal closure was carried out in 75 of 107 patients at a mean of 3.4 +/- 0.3 days after OS. Fifty of these 75 (67%) survived and were discharged an average of 43 +/- 6 days after closure. Fifty-seven patients died: 32 before DSC at 3.7 +/- 0.8 days after OS and 25 after DSC at 27 +/- 4 days after OS. Baseline cardiac index (1.7 +/- 0.1 L.min-1.m-2) improved an average of 1.0 +/- 0.1 L.min-1.m-2 after OS (p less than or equal to 0.001) and remained stable through DSC (2.5 +/- 0.3 L.min-1.m-2) and late (9 +/- 0.7 days) follow-up (2.8 +/- 0.1 L.min-1.m-2). Delayed sternal closure in patients without ventricular assist devices was significantly more likely to be successful (45/63 versus 9/27; p less than 0.002) when carried out after the onset of a negative daily fluid balance. Sternal infection occurred in 4 of 75 (5%) patients after DSC and was associated with bleeding as an indication for OS (3/15 versus 1/60; p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
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              Application of transesophageal echocardiography to continuous intraoperative monitoring of left ventricular performance.

              Y Oka, Jens Strom, Jordan Becker … (1980)
              Transesophageal M mode echocardiography was used for continuous monitoring of left ventricular dimensions in 21 patients (11 with valvular and 10 with coronary heart disease) undergoing open heart surgery. Echocardiograms were recorded in six stages of the procedure and simultaneous measurements of cardiac output (with dye dilution) and atrial pressures were made. Measurements of left ventricular diameters with the transesophageal technique correlated excellently with the corresponding measurements obtained with the standard parasternal method. In patients with volume overload, surgical correction was accompanied by a decrease in diastolic dimension, velocity of circumferential fiber shortening, mid wall stress and end-diastolic stiffness, and an increase in cardiac output. Pericardial and chest wall closures generally caused a significant decrease in cardiac output, and correlated with a decrease in diastolic diameter and an increase in the stiffness constant of the left ventricle. Thus, the decrease in cardiac output may have been due to decreased distensibility of the ventricular cavity secondary to mechanical restriction by the pericardium and chest wall. Pericardial opening caused a significant delay in septal motion that was reversed by closing the pericardium. This study confirms the validity of transesophageal echocardiography and its usefulness in monitoring changes in ventricular function during cardiac surgery.
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                Author and article information

                Contributors
                Roh Yanagida:
                ORCID: http://orcid.org/0000-0002-4474-8075
                310-614-9614 , ryanagida@att.net
                Journal
                Journal ID (nlm-ta): J Artif Organs
                Journal ID (iso-abbrev): J Artif Organs
                Title: Journal of Artificial Organs
                Publisher: Springer Japan (Tokyo )
                ISSN (Print): 1434-7229
                ISSN (Electronic): 1619-0904
                Publication date (Electronic): 25 September 2017
                Publication date PMC-release: 25 September 2017
                Publication date (Print): 2018
                Volume: 21
                Issue: 1
                Pages: 46-51
                Affiliations
                [1 ]ISNI 0000 0000 8417 1093, GRID grid.416154.3, Department of Cardiothoracic Surgery, , Newark Beth Israel Medical Center, ; 201 Lyons Avenue, Newark, NJ 07112 USA
                [2 ]ISNI 0000 0004 1936 8438, GRID grid.266539.d, Division of Cardiology, , University of Kentucky, ; Lexington, USA
                [3 ]ISNI 0000 0004 1936 8438, GRID grid.266539.d, Department of Surgery, , University of Kentucky, ; Lexington, USA
                [4 ]ISNI 0000 0004 1936 8438, GRID grid.266539.d, Division of Cardiothoracic Surgery, Department of Surgery, , University of Kentucky, ; Lexington, USA
                [5 ]ISNI 0000000106344187, GRID grid.265892.2, Division of Cardiothoracic Surgery, Department of Surgery, , University of Alabama, ; Birmingham, USA
                Author information
                http://orcid.org/0000-0002-4474-8075
                Article
                Publisher ID: 996
                DOI: 10.1007/s10047-017-0996-z
                PMC ID: 5816763
                PubMed ID: 28948385
                SO-VID: 9d420d4d-2f3a-45c6-8428-3d834c345a30
                Copyright © © The Author(s) 2017
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 4 May 2017
                Date accepted : 18 September 2017
                Categories
                Subject: Original Article
                Custom metadata
                issue-copyright-statement © The Japanese Society for Artificial Organs 2018

                Keywords: left ventricular assist device,delayed sternal closure,right ventricular failure,vacuum assist device,coagulopathy
                Data availability:
                Keywords: left ventricular assist device, delayed sternal closure, right ventricular failure, vacuum assist device, coagulopathy

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