title: Outcomes of delayed chest closure after bilateral lung transplantation.
abstract: BACKGROUND
  Delayed chest closure (DCC) may be used after bilateral lung transplantation when significant bleeding/coagulopathy or severe pulmonary edema exists. Primary chest closure (PCC) in these patients can lead to heart and lung compression causing cardiopulmonary instability. The purpose of this study is to describe factors associated with DCC and evaluate outcomes after DCC.
  
  
  METHODS
  We performed a retrospective review of all patients undergoing bilateral lung transplantation between September 2003 and March 2005. Statistical significance was determined by two-tailed t test or Fisher's exact test.
  
  
  RESULTS
  Twenty-eight bilateral lung transplantations were performed. Indication for transplant was chronic obstructive pulmonary disease (13), pulmonary fibrosis (5), cystic fibrosis (5), sarcoidosis (3), and pulmonary hypertension (1). Seven patients (25%) required DCC. Mean time to DCC was 5.3 days. Six patients (86%) with DCC required tracheostomy versus 4 patients (20%) with PCC (p = 0.003). Mean days to discharge was 44 in the DCC group and 21 in the PCC group (p = 0.03). Thirty-day survival was 100% in the DCC group and 95% in the PCC group (p = 1.0). There were no wound infections in either group, and 1 patient in the PCC group had sternal nonunion. Delayed chest closure was associated with cardiopulmonary bypass use (p = 0.006), cardiopulmonary bypass time longer than mean cardiopulmonary bypass time (mean, 224 minutes; p = 0.04), PaO2/FiO2 less than mean + 1 SD (value = 4.63, p = 0.0002), evidence of moderate/severe reperfusion injury on chest radiograph (p = 0.0002), and PaO2/FiO2 less than mean plus moderate/severe reperfusion injury on chest radiograph (p = 0.002).
  
  
  CONCLUSIONS
  Cardiopulmonary bypass use, prolonged cardiopulmonary bypass time, and significant reperfusion injury, as determined by chest radiograph and a low PaO2/FiO2 ratio were all associated with an increased incidence of DCC in our bilateral lung transplantation patients. These patients had no wound infections or sternal complications, and although they had longer hospital stays than PCC patients, DCC did not affect operative survival. Delayed chest closure can be employed safely, when necessary, after bilateral lung transplantation with outcomes similar to patients with PCC.
authors.affiliation: Division of Cardiothoracic Surgery, Emory University Hospital and Clinic, Atlanta, Georgia, USA. sethforce@emoryhealthcare.org
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Miller
authors.forename: Andres
authors.initials: A
authors.lastname: Pelaez
authors.forename: Allan M
authors.initials: AM
authors.lastname: Ramirez
authors.forename: David
authors.initials: D
authors.lastname: Vega
authors.forename: Benjamin
authors.initials: B
authors.lastname: Barden
authors.forename: E Clinton
authors.initials: EC
authors.lastname: Lawrence
mesh_terms: D016063:Blood Loss, Surgical; D001864:Bone Wires; D009202:Cardiomyopathies; D002315:Cardiopulmonary Bypass; D004487:Edema; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary; D007431:Intraoperative Complications; D016040:Lung Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009779:Occlusive Dressings; D011184:Postoperative Period; D011654:Pulmonary Edema; D015427:Reperfusion Injury; D012189:Retrospective Studies; D013249:Sternum / Q000601:surgery; D013536:Suture Techniques; D013908:Thoracotomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome