title: Delayed Sternal Closure in Infant Heart Surgery-The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database.
abstract: BACKGROUND
  Delayed sternal closure (DSC) is commonly used to optimize hemodynamic stability after neonatal and infant heart surgery. We hypothesized that duration of sternum left open (SLO) was associated with rate of infection complications, and that location of sternal closure may mitigate infection risk.
  
  
  METHODS
  Infants (age ≤365 days) undergoing index operations with cardiopulmonary bypass and DSC at STS Congenital Heart Surgery Database centers (from 2007 to 2013) with adequate data quality were included. Primary outcome was occurrence of infection complication, defined as one or more of the following: endocarditis, pneumonia, wound infection, wound dehiscence, sepsis, or mediastinitis. Multivariable regression models were fit to assess association of infection complication with: duration of SLO (days), location of DSC procedure (operating room versus elsewhere), and patient and procedural factors.
  
  
  RESULTS
  Of 6,127 index operations with SLO at 100 centers, median age and weight were 8 days (IQR, 5-24) and 3.3 kg (IQR, 2.9-3.8); 66% of operations were STAT morbidity category 4 or 5. At least one infection complication occurred in 18.7%, compared with 6.6% among potentially eligible neonates and infants without SLO. Duration of SLO (median, 3 days; IQR, 2-5) was associated with an increased rate of infection complications (p < 0.001). Location of DSC procedure was operating room (16%), intensive care unit (67%), or other (17%). Location of DSC was not associated with rate of infection complications (p = 0.45).
  
  
  CONCLUSIONS
  Rate of occurrence of infectious complications is high among infants with sternum left open following cardiac surgery. Longer duration of SLO is associated with increased infection complications.
authors.affiliation: Departments of Anesthesia and Critical Care Medicine, and Pediatrics, Division of Pediatric Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: knelso23@jhmi.edu.
authors.forename: Kristen
authors.initials: K
authors.lastname: Nelson-McMillan
authors.affiliation: Department of Pediatrics, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Christoph P
authors.initials: CP
authors.lastname: Hornik
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Xia
authors.initials: X
authors.lastname: He
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Luca A
authors.initials: LA
authors.lastname: Vricella
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Jacobs
authors.affiliation: Department of Pediatrics, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Hill
authors.affiliation: Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Heart Center, CS Mott Children's Hospital, Ann Arbor, Michigan.
authors.forename: Sara K
authors.initials: SK
authors.lastname: Pasquali
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Diane E
authors.initials: DE
authors.lastname: Alejo
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Duke E
authors.initials: DE
authors.lastname: Cameron
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Marshall L
authors.initials: ML
authors.lastname: Jacobs
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods*; D004696:Endocarditis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery; D006439:Hemodynamics; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D008480:Mediastinitis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D009873:Operating Rooms; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D012042:Registries; D018805:Sepsis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D056346:Sternotomy / Q000009:adverse effects; D013529:Surgical Wound Dehiscence / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D058106:Wound Closure Techniques