Cardiology, Inside Pediatrics

Comparing Delayed Sternal Closure Results Reinforces Success at Children’s of Alabama

Leaving the chest open for a day or two after complex neonatal heart surgery has been standard procedure at Children’s of Alabama for about a dozen years. The practice is believed to be a “safety mechanism” that lessens compression on the heart and lungs as swollen babies begin to recover from their operations, according to Robert Dabal, M.D., chief of pediatric cardiothoracic surgery at Children’s and an associate professor of surgery at the University of Alabama at Birmingham (UAB).

But does the approach, known as delayed sternal closure, actually produce better outcomes than closing a newborn’s chest at the conclusion of surgery? The Pediatric Cardiac Critical Care Consortium (PC4) recently invited Children’s and University of Michigan’s C.S. Mott Children’s Hospital to debate the question by comparing each hospital’s outcomes. Unlike standard practice at Children’s, C.S. Mott cardiothoracic surgeons “tend to close a lot of complex neonates,” Dabal explained.

Children’s has been a member of PC4 – which aims to improve the quality of care to patients in North America and beyond with critical pediatric and congenital cardiovascular disease – since the group’s inception about 12 years ago. The head-to-head comparison of outcomes between Children’s and C.S. Mott showed survival rates to be higher at Children’s, though the gap was not statistically significant, Dabal said.

“We found that delayed sternal closure doesn’t really negatively impact patients in any way, either in length of stay or rate of complications, but it does make them a little easier to manage in the immediate postoperative period,” he said.

Mortality rates at Children’s for complex neonatal heart surgeries are consistently far lower than the U.S. average, he noted. For example, for the Norwood procedure – a three-step heart surgery for hypoplastic left heart syndrome – Children’s mortality rate has been about 5.5% over the last five years, compared with a national average of about 15%.

Possible complications from leaving the chest open after surgery include slightly higher odds of infection, “though we haven’t really seen that here,” Dabal said. The practice also requires greater sedation to prevent patients from “moving around a lot” in the days after surgery and a slight delay in removing ventilators.

But the PC4 debate results essentially reinforce Children’s approach, and Dabal expects delayed sternal closure to continue here as the standard of care. “I don’t think we’ll be making major changes, though we’re always interested in continuing to improve our results,” he said.

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