Repeat sternotomy for congenital heart surgery—impact of inadvertent cardiac injury

To assess the impact of complications resulting from inadvertent cardiac injury occurring during repeat sternotomy (RS) for congenital heart surgery and identify possible predisposing risk factors for this eventuality.

A retrospective observational study was initiated to investigate complications related to RS in congenital heart surgery. Hospital records of patients who underwent RS from January 2016 to December 2020 in the department of Paediatric and Congenital Heart Surgery were reviewed. Preoperative, operative, and post-operative datasets were collected and analysed for incidence of inadvertent cardiac injury and its impact on subsequent clinical course. An attempt was made to identify possible predisposing factors that might contribute to this complication.

The study included a total of 261 patients. During RS cardiac injury occurred in 10 patients (3.83%). Postoperatively, organ dysfunction was observed in 49 patients (18.77%), sternal wound infection in 7 patients (2.68%), and pulmonary complications and arrhythmias were both observed in 12 patients each (4.60%). Thirty-day mortality was 1.53% (4/261). Patients who had cardiac injury during sternotomy had significantly higher mortality (20% vs 0.8%, p = 0.007), organ dysfunction (40% vs 9.56%, p = 0.01), sternal wound infection (20% vs 1.99%, p = 0.02), and overall complications (70% vs 19.12%, p = 0.002). Cardio-pulmonary bypass (CPB) time (p = 0.02), aortic cross clamp time (p = 0.04), chest tube drainage (p = 0.04), ventilation time (p = 0.0014), and female gender (p = 0.04) were predictors of organ dysfunction but not mortality. Female gender (p = 0.043) and cardiac injury (p = 0.018) were the predictors of the sternal wound infection. Cardiac injury during sternotomy was the only predictor (p = 0.029) of mortality.

Reoperations are a necessity in many forms of congenital heart disease (CHD) surgery. Inadvertent cardiac injury during RS adversely impacted survival in our study. On the other hand, the number of previous sternotomies, duration of surgery, interval from previous sternotomy, and CPB time had no impact on mortality as long as cardiac injury was avoided. Every possible measure must therefore be taken to avoid inadvertent cardiac injury during RS in children with CHD.