title: How to do safe sternal reentry and the risk factors of redo cardiac surgery: a 21-year review with zero major cardiac injury.
abstract: OBJECTIVE
  Resternotomy is a common part of cardiac surgical practice. Associated with resternotomy are the risks of cardiac injury and catastrophic hemorrhage and the subsequent elevated morbidity and mortality in the operating room or during the postoperative period. The technique of direct vision resternotomy is safe and has fewer, if any, serious cardiac injuries. The technique, the reduced need for groin cannulation and the overall low operative mortality and morbidity are the focus of this restrospective analysis.
  
  
  METHODS
  The records of 495 patients undergoing 546 resternotomies over a 21-year period to January 2000 were reviewed. All consecutive reoperations by the one surgeon comprised patients over the age of 20 at first resternotomy: M:F 343:203, mean age 57 years (range 20 to 85, median age 60). The mean NYHA grade was 2.3 [with 67 patients (I), 273 (II), 159 (III), 43 (IV), and 4 (V classification)] with elective reoperation in 94.6%. Cardiac injury was graded into five groups and the incidence and reasons for groin cannulation estimated. The morbidity and mortality as a result of the reoperation and resternotomy were assessed.
  
  
  RESULTS
  The hospital/30 day mortality was 2.9% (95% CI: 1.6%-4.4%) (16 deaths) over the 21 years. First (481), second (53), and third (12) resternotomies produced 307 uncomplicated technical reopenings, 203 slower but uncomplicated procedures, 9 minor superficial cardiac lacerations, and no moderate or severe cardiac injuries. Direct vision resternotomy is crystalized into the principle that only adhesions that are visualized from below are divided and only sternal bone that is freed of adhesions is sewn. Groin exposure was never performed prophylactically for resternotomy. Fourteen patients (2.6%) had such cannulation for aortic dissection/aneurysm (9 patients), excessive sternal adherence of cardiac structures (3 patients), presurgery cardiac arrest (1 patient), and high aortic cannulation desired and not possible (1 patient). The average postop blood loss was 594 mL (95% CI:558-631) in the first 12 hours. The need to return to the operating room for control of excessive bleeding was 2% (11 patients). Blood transfusion was given in 65% of the resternotomy procedures over the 21 years (mean 854 mL: 95% CI 765-945 mL) and 41% over the last 5 years.
  
  
  CONCLUSIONS
  The technique of direct vision resternotomy has been associated with zero moderate or major cardiac injury/catastrophic hemorrhage at reoperation. Few patients have required groin cannulation. In the postoperative period, there was acceptable blood loss, transfusion rates, reduced morbidity, and moderate low mortality for this potentially high risk group.
authors.affiliation: Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Australia. Mark_OBrien@health.qld.gov.au
authors.forename: M F
authors.initials: MF
authors.lastname: O'Brien
authors.forename: S
authors.initials: S
authors.lastname: Harrocks
authors.forename: A
authors.initials: A
authors.lastname: Clarke
authors.forename: B
authors.initials: B
authors.lastname: Garlick
authors.forename: A G
authors.initials: AG
authors.lastname: Barnett
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D015331:Cohort Studies; D001026:Coronary Artery Bypass; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery; D006335:Heart Injuries / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000209:etiology; D012086:Reoperation; D012307:Risk Factors; D012720:Severity of Illness Index; D013249:Sternum / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome