# Sternal Complications After Clamshell Surgery for (Heart-)Lung Transplantation—A Systematic Literature Review

## TL;DR

This review examines the high rate of sternal complications after clamshell surgery used in heart-lung and lung transplants.

## Contribution

The study provides a systematic review of sternal complication prevalence after clamshell surgery in transplant patients.

## Key findings

- 286 sternal complications were reported among 830 clamshell surgeries, with a mean of 0.34 events per surgery.
- 90 sternal reoperations were conducted, averaging 0.14 reoperations per clamshell surgery.
- Study quality was generally poor, with significant heterogeneity preventing meta-analysis.

## Abstract

Bilateral transverse thoracosternotomy (“clamshell”) is widely used for (heart-)lung transplantations, but postoperative sternal complications are a significant challenge. The primary objective of this systematic review was to evaluate the prevalence of sternal complications after clamshell surgery in (heart-)lung transplantation patients.

A systematic literature review was conducted. On April 4, 2025, PubMed and Embase databases were searched. Original studies reporting sternal complications after clamshell surgery in adults for bilateral lung or heart-lung transplantation were included. Studies including <10 patients were excluded. Study quality was assessed using the National Institutes of Health assessment tool. The total and range of sternal complication prevalence was provided. Meta-analysis of sternal complication prevalence was not performed due to significant heterogeneity across studies.

The database searches yielded 945 eligible articles. Eighteen studies were included, including 828 patients who underwent a total of 830 bilateral lung or heart-lung transplantations through clamshell surgery. All included studies were cohort studies with poor (n = 15), fair (n = 1), or good (n = 2) quality. In total, 286 sternal complications were reported (0.34 event per clamshell surgery; range 0.02 to 1.35 in individual studies) and 90 sternal reoperations were conducted (0.14 reoperation per clamshell surgery; range 0.02 to 0.29 in individual studies).

Despite limitations in study quality and heterogeneity, this review highlights the high prevalence and relevance of sternal complications following clamshell surgery for (heart-)lung transplantation. Future studies should focus on patient selection, risk stratification, development of modified sternal closure techniques, and implementation of alternative surgical approaches to (heart-)lung transplantation.

The clamshell approach, a bilateral transverse thoracosternotomy usually performed in the third, fourth, or fifth intercostal space, is the conventional surgical approach for bilateral lung transplantation and sometimes also used for heart-lung transplantation.