title: Is resternotomy a risk for continuous-flow left ventricular assist device outcomes?
abstract: BACKGROUND
  The number of patients undergoing resternotomy continues to rise. Although catastrophic hemorrhage remains a dreaded complication, most published data suggest that sternal reentrance is safe, with negligible postoperative morbidity and mortality. A significant proportion of left ventricular assist device (LVAD) implantations are reoperative cardiac procedures. The aim of our study was to compare outcomes between first time sternotomy and resternotomy patients receiving continuous-flow LVADs, as a bridge to transplantation or destination therapy.
  
  
  METHODS
  From March 2006 through February 2012, 100 patients underwent implantation of a HeartMate II or HeartWare LVAD at our institution. Patients were stratified into two groups, primary sternotomy and resternotomy. Variables were compared using two-sided t-tests, chi-square tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the two groups and if resternotomy was a significant independent predictor of outcome.
  
  
  RESULTS
  We identified 29 patients (29%) who had resternotomy and 71 patients (71%) who had first time sternotomy. The resternotomy group was significantly older (56 years vs. 51 years, p = 0.05), was more likely to have ischemic cardiomyopathy (ICM) (69% vs. 30%, p < 0.001), chronic obstructive pulmonary disease (COPD) (31% vs. 14%, p = 0.05) and had longer cardiopulmonary bypass times (135 min vs. 100 min, p = 0.011). Survival rates at 30 days (93.1% vs. 95.8%, p = 0.564), 180 days (82.8% vs. 93%, p = 0.131), and 360 days (82.8% vs. 88.7%, p = 0.398) were similar for the resternotomy and primary sternotomy groups, respectively. Postoperative complications were also comparable, except for re-exploration for bleeding which was higher for the resternotomy group (17.2% vs. 4.2%, p = 0.029), although blood transfusion requirements were not significantly different (1.4 units vs. 1.2 units, p = 0.815). Left and right heart catheterization measurements and echocardiographic (ECHO) findings after 1 and 6 months of LVAD therapy were similar between the two groups.
  
  
  CONCLUSIONS
  Survival at 30, 180, and 360 days after LVAD implantation is similar between the resternotomy and primary sternotomy group. No major differences in complications or hemodynamic measurements were observed. Although a limited observational study, our findings agree with previously published resternotomy outcomes.
authors.affiliation: Division of Cardiothoracic Surgery, Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan, USA. atsiour1@hfhs.org
authors.forename: Athanasios
authors.initials: A
authors.lastname: Tsiouris
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Brewer
authors.forename: Jamil
authors.initials: J
authors.lastname: Borgi
authors.forename: Arielle
authors.initials: A
authors.lastname: Hodari
authors.forename: Hassan W
authors.initials: HW
authors.lastname: Nemeh
authors.forename: Chad M
authors.initials: CM
authors.lastname: Cogan
authors.forename: Gaetano
authors.initials: G
authors.lastname: Paone
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Morgan
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D016009:Chi-Square Distribution; D005260:Female; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012086:Reoperation / Q000401:mortality; D012306:Risk; D056346:Sternotomy / Q000706:statistics & numerical data; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome