Mortality Rate After Clamshell Thoracotomy
The mortality rate following emergency clamshell thoracotomy is extremely high, with survival rates of only 9-12% for penetrating trauma and 1-2% for blunt trauma. 1
Mortality Rates by Context
Emergency/Trauma Setting
- Emergency department clamshell thoracotomy for traumatic injuries has a very poor prognosis with survival rates of 9-12% for penetrating trauma and only 1-2% for blunt trauma 1
- Resuscitative emergency thoracotomy success rates range from 7-21%, with higher success rates in patients who lose vital signs for less than 45 minutes 2
- Mortality is significantly affected by associated injuries such as stroke, mesenteric ischemia, renal failure, and myocardial ischemia 2
Elective/Planned Procedures
- For elective clamshell procedures in pediatric patients with complex cardiovascular or pulmonary anomalies, the perioperative mortality rate is approximately 6% 3
- Hemiclamshell approach (longitudinal partial sternotomy with anterolateral thoracotomy) has a one-month mortality rate of 6% 4
- When clamshell incision is used for bilateral lung transplantation, the approach carries significant morbidity and wound complications 5
Factors Affecting Mortality
Procedure Type and Extent
- Total arch replacement procedures using clamshell approach carry a 2-7% risk of death and 2-7% risk of stroke in elective cases, with rates increasing to 15% mortality and 14% stroke in emergency operations 2
- Thoracoabdominal repairs have mortality rates strongly influenced by the urgency of surgery, with Crawford Type I repairs having approximately 5% mortality, doubling to 10% for Type II repairs 2
Patient Factors
- Mortality is significantly higher in elderly patients and those with comorbidities 2
- For patients with Marfan syndrome, connective tissue disorders, or bicuspid aortic valves who undergo appropriate surgical repair, the long-term prognosis is better 2
Alternative Approaches
- Sternum-sparing techniques (bilateral sequential anterolateral thoracotomies without sternal division) have been developed to reduce the morbidity associated with the traditional clamshell approach 6
- This less invasive approach has shown promising results with 100% three-month survival in one series of bilateral lung transplantation patients 6
Complications Contributing to Mortality
- Postoperative hemorrhage occurs in approximately 12% of patients undergoing clamshell thoracotomy 3
- Prolonged ventilation due to mechanical failure is reported in 12% of cases 3
- Wound complications including infection and lung herniation may require additional surgical intervention 5
- Chylothorax and phrenic nerve paralysis are reported complications following hemiclamshell approach 4
Risk Reduction Strategies
- Careful patient selection with preoperative cardiac and respiratory assessment is mandatory and could significantly improve outcomes 2
- For trauma cases requiring clamshell thoracotomy, immediate transfer to the operating room for definitive surgical treatment after initial resuscitation is critical 1
- Alternative, less invasive approaches such as bilateral sequential anterolateral thoracotomies without sternal division may reduce mortality by minimizing operative trauma and improving postoperative functional recovery 6
The mortality rate after clamshell thoracotomy varies significantly based on the clinical context, with emergency trauma cases having extremely poor outcomes compared to elective procedures. The high mortality rate underscores the need for careful patient selection, appropriate surgical expertise, and consideration of alternative, less invasive approaches when feasible.