Routine Primary Sternal Closure After the Norwood Procedure

Abstract

Background: Delayed sternal closure (DSC) is frequently utilized to facilitate the recovery of myocardial function and edema following the Norwood procedure. At our institution, most patients undergo primary sternal closure (PSC), unless specified high-risk characteristics are present. We sought to analyze the outcomes of our approach. Methods: A retrospective review was performed of patients who underwent the Norwood procedure from 2017 to 2022. Patients were divided into two groups-PSC and DSC. Baseline demographics, clinical characteristics, and perioperative details were compared. The primary outcomes of interest were operative survival and infectious complications. Results: The Norwood procedure was performed in 116 neonates, of whom 80 (68.9%) underwent PSC. Baseline clinical characteristics and echocardiographic findings were not different between groups, except for lower preoperative inotrope use in the PSC group (13/80 [16.3%] vs 15/36 [41.7%], P = .003). Perioperatively, PSC patients were less likely to have multiple bypass runs (3/80 [3.8%] vs 9/36 [25.0%], P < .001) and less postoperative mechanical circulatory support (6/80 [7.5%] vs 12/36 [33.3%], P < .001). Hospital survival was higher (73/80 [[91.3%] vs 24/36 [66.7%], P = .04), and length of stay was shorter (29.0 vs 78.0 days, P < .001) with PSC. Of the 80 patients in the PSC group 5 (6.2%) required reopening of the sternum. By multivariable analysis, DSC was not an independent risk factor for operative mortality (OR 1.42 [95% CI 0.33-6.02], P = .63) or infection (OR 2.22 [95% CI 0.74-6.60], P = .15). Conclusions: Primary sternal closure can be performed in most patients following the Norwood procedure with favorable outcomes. Selected patients with high-risk preoperative or intraoperative features may benefit from DSC. Delayed sternal closure does not independently increase the risk of mortality or infectious complications.

Keywords: Norwood; hypoplastic left heart syndrome; neonate; sternum.