title: Delayed Sternal Closure After Continuous Flow Left Ventricle Assist Device Implantation: Analysis of Risk Factors and Impact on Outcomes and Costs.
abstract: Patient and institutional factors predictive of delayed sternal closure (DSC) practice and its impact on clinical and cost outcomes when compared with primary sternal closure (PSC) following continuous-flow left ventricular assist device (CF-LVAD) implantation were examined. Statewide Society of Thoracic Surgeons and hospital cost data on CF-LVADs implanted were analyzed. Between January 2007 and December 2013, 558 CF-LVADs were implanted (PSC = 464, 83.2%; DSC = 94, 16.8%). Among the six institutions implanting CF-LVADs, DSC practice ranged from 3.1% to 37.8%. Compared with PSC, the DSC group had higher body mass index (BMI), renal failure, anemia, IIb/IIIa inhibitor use, emergency surgery, and extracorporeal membrane oxygenation (ECMO) support. Delayed sternal closure patients had significantly longer bypass time (139 ± 63 min vs. 107.6 ± 42 min) and higher use of intraoperative blood products (82% vs. 69%) and right ventricular assist device (RVAD) support (4.3% vs. 0.2%). Postoperative morbidities and mortality (23.4% vs. 6.5%; p ≤ 0.0001) were higher in the DSC group compared with PSC. Mean hospital costs for DSC were higher than PSC ($249,144 ± 123,273 vs. $155,915 ± 95,032; p ≤ 0.0001). Multivariate predictors of DSC include institution with higher DSC practice, preoperative ECMO support, use of IIb/IIIa inhibitors, tricuspid valve surgery, and intraoperative red blood cell transfusion. Delayed sternal closure was an independent risk factor for postoperative mortality, odds ratio 3.0 (1.2-7.2).
authors.affiliation: From the *Virginia Commonwealth University, Richmond, Virginia; †University of Virginia, Charlottesville, Virginia; ‡VCSQI, Washington, District of Columbia; and §Cardiac, Vascular and Thoracic Surgery Associates, Falls Church, Virginia.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Quader
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.forename: Luke
authors.initials: L
authors.lastname: Wolfe
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Rich
authors.forename: Alan
authors.initials: A
authors.lastname: Speir
authors.forename: Clifford
authors.initials: C
authors.lastname: Fonner
authors.forename: Vigneshwar
authors.initials: V
authors.lastname: Kasirajan
mesh_terms: D000328:Adult; D000368:Aged; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D017048:Health Care Costs; D006353:Heart-Assist Devices / Q000009:adverse effects* / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D013249:Sternum / Q000601:surgery*