The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 5 , Pages 1205-1210, May 2010

Center variation and outcomes associated with delayed sternal closure after stage 1 palliation for hypoplastic left heart syndrome

  • Jason N. Johnson, MD

      Affiliations

    • Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC
    • ,
  • James Jaggers, MD

      Affiliations

    • Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
    • ,
  • Shuang Li, MS

      Affiliations

    • Duke Clinical Research Institute, Durham, NC
    • ,
  • Sean M. O'Brien, PhD

      Affiliations

    • Duke Clinical Research Institute, Durham, NC
    • ,
  • Jennifer S. Li, MD, MHS

      Affiliations

    • Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Durham, NC
    • ,
  • Jeffrey P. Jacobs, MD

      Affiliations

    • Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida, All Children's Hospital and Children's Hospital of Tampa, University of South Florida College of Medicine, St Petersburg and Tampa, Fla
    • ,
  • Marshall L. Jacobs, MD

      Affiliations

    • Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio
    • ,
  • Karl F. Welke, MD

      Affiliations

    • Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Ore
    • ,
  • Eric D. Peterson, MD, MPH

      Affiliations

    • Duke Clinical Research Institute, Durham, NC
    • ,
  • Sara K. Pasquali, MD

      Affiliations

    • Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Durham, NC
    • Corresponding Author InformationReprint requests: Sara K. Pasquali, MD, Assistant Professor of Pediatrics, Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715.

Received 23 June 2009; received in revised form 14 October 2009; accepted 14 November 2009. published online 18 February 2010.

Objective

There is debate whether primary or delayed sternal closure is the best strategy after stage 1 palliation for hypoplastic left heart syndrome. We describe center variation in delayed sternal closure after stage 1 palliation and associated outcomes.

Methods

Society of Thoracic Surgeons Congenital Database participants performing stage 1 palliation for hypoplastic left heart syndrome from 2000 to 2007 were included. We examined center variation in delayed sternal closure and compared in-hospital mortality, prolonged length of stay (length of stay > 6 weeks), and postoperative infection in centers with low (≤25% of cases), middle (26%–74% of cases), and high (≥75% of cases) delayed sternal closure use, adjusting for patient and center factors.

Results

There were 1283 patients (45 centers) included. Median age at surgery was 6 days (interquartile range, 4–9 days), and median weight at surgery was 3.2 kg (interquartile range, 2.8–3.5 kg); 59% were male. Delayed sternal closure was used in 74% of cases (range, 3%–100% of cases/center). In centers with high (n = 23) and middle (n = 17) versus low (n = 5) delayed sternal closure use, there was a greater proportion of patients with prolonged length of stay and infection, and a trend toward increased in-hospital mortality in unadjusted analysis. In multivariable analysis, there was no difference in mortality. Centers with high and middle delayed sternal closure use had prolonged length of stay (odds ratio, 2.83; 95% confidence interval, 1.46–5.47; P = .002 and odds ratio, 2.23; confidence interval, 1.17–4.26; P = .02, respectively) and more infection (odds ratio, 2.34; confidence interval, 1.20–4.57; P = .01 and odds ratio, 2.37; confidence interval, 1.36–4.16; P = .003, respectively).

Conclusion

Use of delayed sternal closure after stage 1 palliation varies widely. These observational data suggest that more frequent use of delayed sternal closure is associated with longer length of stay and higher postoperative infection rates. Further evaluation of the risks and benefits of delayed sternal closure in the management of these complex infants is necessary.

CTSNet classification: 20, 21

Abbreviations and Acronyms: CI, confidence interval, DSC, delayed sternal closure, HLHS, hypoplastic left heart syndrome, OR, odds ratio, STS, Society of Thoracic Surgeons

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 Disclosures: None.

 Dr Pasquali receives grant support (KL2 RR024127-02) from the National Center for Research Resources, a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research, and from the American Heart Association Mid-Atlantic Affiliate Clinical Research Program. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of National Center for Research Resources, NIH, or American Heart Association.

PII: S0022-5223(09)01485-8

doi:10.1016/j.jtcvs.2009.11.029

The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 5 , Pages 1205-1210, May 2010

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