Enhancing Outcomes After Sternotomy in Cardiac Surgery: A Three-Pillar Strategy for Better Recovery

Median sternotomy remains the gold standard for surgical access in the majority of open-heart procedures, providing reliable exposure for complex cardiac operations. Despite advances in surgical technique and perioperative care, it continues to be associated with significant complications, including bleeding, fragile or calcified tissue and sternal instability, and surgical site infections (SSIs). These complications are not isolated but are deeply interconnected, often progressing in a vicious cycle that leads to increased morbidity, mortality, prolonged hospitalization, and substantial healthcare costs. Although the individual challenges of median sternotomy have been extensively studied, a comprehensive synthesis that conceptualizes an integrated framework for optimizing outcomes is lacking. This review proposes a novel three-pillar Comprehensive Sternotomy Management Bundle that simultaneously addresses (1) perioperative bleeding management, (2) handling of fragile or calcified tissue with robust sternal stabilization, and (3) multimodal prevention of SSI. By integrating evidence-based strategies across the preoperative, intraoperative, and postoperative phases, the bundle aims to disrupt the cycle of complications, promote secure sternal healing, reduce transfusion requirements, and accelerate recovery. This multimodal care bundle aligns with the Quintuple Aim by improving clinical outcomes, enhancing the patient and clinician experience, and reducing overall healthcare costs in an increasingly older and comorbid cardiac surgical population.