Medical Student McGill University Montréal, Quebec, Canada
Background: Acute type A aortic dissection is a life-threatening condition requiring emergency surgical repair. Patients are at increased risk of perioperative coagulopathy and hemodynamic instability, prompting some surgeons to leave the chest open and return to the operating room (OR) in 48-72 hours for delayed sternal closure (DSC). One may tend to think that DSC will result in increased post-operative complications in those patients, yet this remains understudied. We aimed to assess whether there are differences in outcomes after acute type A aortic dissection repair in patients undergoing DSC versus primary sternal closure (PSC).
METHODS AND RESULTS: This was a single-center retrospective study that included 130 adult patients presenting with acute type A aortic dissection for which they underwent surgery between 2016-2024. Patients left the OR with either a closed chest (PSC) or an open chest for DSC. The primary outcome was all-cause mortality at 90 days post-operatively. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), post-operative infection (superficial and deep sternal wound infection, pericarditis, graft infection, bacteremia, pneumonia), 5-year mortality, and various other post-operative complications. Analysis was conducted on IBM SPSS, with statistical significance set at p< 0.05. Out of 130 patients, 23% (n=30) left the OR with an open chest with a median time to DSC of 2[2;3] days. Cardiopulmonary bypass time was significantly higher in open versus closed chest patients (Open chest: 237.9±76.4, Closed chest: 194.0±51.8 min, p=0.006). The 90-day mortality rate was 20.0% (n=26), with no significant difference between open versus closed chest patients (Open chest: 23.3%, n=7; Closed chest: 19.0%, n=19; p=0.60, RR 1.2[0.6;2.6]). There was no significant difference in ICU or hospital length of stay (ICU: Open chest: 9.8±11.0, Closed chest: 9.0±12.3 days, p=0.18; Hospital: Open chest: 22.2±18.4, Closed chest: 20.2±22.8 days, p=0.21). Moreover, there was no significant difference in post-operative infection (Open chest: 30.0%, n=9; Closed chest: 24.0%, n=24; p=0.51, RR 1.3[0.7;2.4]) or 5-year mortality (Open chest: 26.7%, n=8; Closed chest: 25.0%, n=25; p=0.86, RR 1.1[0.5;2.1]).
Conclusion: In patients presenting with acute type A aortic dissection, post-operative outcomes are similar regardless of whether patients left the OR with a closed chest or with an open chest for DSC. Our findings indicate that leaving the chest open after acute type A aortic dissection repair is not harmful and is an appropriate strategy to mitigate perioperative coagulopathy.
