Assessing Retrosternal Adhesions Using Preoperative CT to Predict Cardiovascular Injury During Sternotomy

Purpose: To identify preoperative CT findings linked to retrosternal adherence-related intraoperative cardiovascular injury and develop predictive scores with the potential to guide surgical planning. Materials and Methods: A retrospective study was conducted on patients undergoing CT within 30 days of sternotomy (first sternotomy or resternotomy) from 2019 to 2023. CT images were reviewed for retrosternal adherence patterns, classified as distance, contact, or adherence, and localized by segment (upper, middle, or lower retrosternal thirds) or by organ (innominate vein, aorta, right ventricle, right atrium, or pulmonary artery). Logistic regression was used to identify the significant predictors from which the scores were developed. Results: Out of 429 patients, 105 (24%) had cardiovascular injuries, including re-entry and postcardiopulmonary bypass injuries. Middle third adherence ( P <0.001), calcification ( P <0.001), and age ( P =0.002) were significant predictors in the segment approach. Aortic ( P =0.001) and right atrial ( P =0.034) adherence, calcification ( P <0.001), and age ( P =0.001) were significant predictors in the organ-specific approach. CAST (Calcification, Age, Sternal Thirds) and ARCA (Aorta, Right Atrium, Calcification, Age) scores were derived to predict intraoperative cardiovascular injuries. Conclusions: Preoperative CT can identify patients at high risk for intraoperative cardiovascular injury during sternotomy. The CAST and ARCA scores offer a reliable, CT-based approach for assessing this risk, potentially enhancing surgical planning and preemptive intervention strategies, thereby improving outcomes in high-risk cardiac reoperations.