Three or more median sternotomies for patients with valve disease: role of computed tomography

Background We evaluated the effects of computed tomographic (CT) scan-guided third or fourth median sternotomies for valve operations on the incidence of resternotomy-related complications and early mortality. Methods Ninety patients undergoing valve replacement with third or fourth time sternotomy were divided into two groups. One group (CT group) consisted of 64 patients who had undergone routine CT scans preoperatively after 1991 to assess the possibility of sternotomy-related bleeding, and the other group (no CT group) comprised the remaining 26 patients who did not receive CT scans. Results Hospital death occurred in 4 patients (6%) in the CT group and in 6 patients (23%) in the no CT group (p = 0.0309). Multivariate analysis indicated NYHA class 4 (odds ratio [OR] = 6.99) and year of operation (OR = 1.05) to be predictors of hospital death. Preoperative CT scans revealed that 8 patients were considered to be high risk for resternotomy, they underwent femorofemoral bypass before sternal division was performed. Hemorrhage occurred upon sternal reentry in 2 of these 8 patients. The incidences of sternotomy-related injury were 19% (5/26) in the no CT group and only 3% (2/64) in the CT group (p = 0.0198). Multivariate analyses demonstrated a fourth sternotomy (OR = 4.31) to be a predictor of resternotomy-related injury. Conclusions CT scans provide preoperative information on retrosternal adhesions. When a distended heart or expanded aorta has adhered to the sternum, femorofemoral cannulation should be performed before sternotomy. Third and fourth sternotomies, though demanding procedures, can be performed safely using the described strategy.