Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis

Vancomycin wound penetration in open-heart surgery patients receiving negative pressure wound therapy for deep sternal wound infection

INTRODUCTION

It is hypothesized that systemically administered antibiotics penetrate wound sites more effectively during negative pressure wound therapy (NPWT). However, there is a lack of clinical data from patients who receive NPWT for deep sternal wound infection (DSWI) after open-heart surgery. Here, we evaluated vancomycin penetration into exudate in this patient group.

PATIENTS AND METHODS

For this prospective observational study, we enrolled 10 consecutive patients treated with NPWT for post-sternotomy DSWI. On the first sampling day, serum and exudate samples were synchronously collected at 0 (pre-dose), 0.5, 1, 2, 3 and 6 h after vancomycin administration. On the following three consecutive days, additional samples were collected, only before vancomycin administration.

RESULTS

The ratio of average vancomycin concentration in wound exudate to in serum was higher for free (unbound) (1.51 ± 0.53) than for total (bound + unbound) (0.91 ± 0.29) concentration (p = 0.049). The percentage of free vancomycin was higher in wound exudate than serum (0.79 ± 0.19 vs. 0.46 ± 0.16; p = 0.04). Good vancomycin wound penetration was maintained on the following three days (vancomycin trough exudate-to-serum concentration ratio > 1). The total hospital stay was significantly longer in patients with DSWI (46 ± 11.6 days) versus without DSWI (14 ± 11.7 days) (p < 0.001). There was no in-hospital or 90-day mortality. Two patients experienced late DSWI recurrence. All-cause mortality was 4.8% during a median follow-up of 2.5 years.

CONCLUSION

Vancomycin effectively penetrates wound exudate in patients receiving NPWT for DSWI after open-heart surgery.The protocol for this study was registered at ClinicalTrials.gov on July 16, 2024 (NCT06506032).

Intra-operative and post-operative management of conduits for coronary artery bypass grafting: a clinical consensus statement of the European Society of Cardiology Working Group on Cardiovascular Surgery and the European Association for Cardio-Thoracic Surgery Coronary Task Force

The structural and functional integrity of conduits used for coronary artery bypass grafting is critical for graft patency. Disruption of endothelial integrity and endothelial dysfunction are incurred during conduit harvesting subsequent to mechanical or thermal injury and during conduit storage prior to grafting, leading to acute thrombosis and early graft failure. Late graft failure, in particular that of vein grafts, is precipitated by progressive atherogenesis. Intra-operative management includes appropriate selection of conduit-specific harvesting techniques and storage solutions. Arterial grafts are prone to vasospasm subsequent to surgical manipulation, and application of intra-operative vasodilatory protocols is critical. Post-operative management includes continuation of oral vasodilator therapy and selection of antithrombotic and lipid-lowering agents to attenuate atherosclerotic disease progression in conduits. In this review, the scientific evidence underlying the key aspects of intra- and post-operative management of conduits for coronary artery bypass grafting is examined. Clinical consensus statements for best clinical practice are provided, and areas requiring further research are highlighted.

Intra-operative and post-operative management of conduits for coronary artery bypass grafting: a clinical consensus statement of the European Society of Cardiology Working Group on Cardiovascular Surgery and the European Association for Cardio-Thoracic Surgery Coronary Task Force

The structural and functional integrity of conduits used for coronary artery bypass grafting is critical for graft patency. Disruption of endothelial integrity and endothelial dysfunction are incurred during conduit harvesting subsequent to mechanical or thermal injury and during conduit storage prior to grafting, leading to acute thrombosis and early graft failure. Late graft failure, in particular that of vein grafts, is precipitated by progressive atherogenesis. Intra-operative management includes appropriate selection of conduit-specific harvesting techniques and storage solutions. Arterial grafts are prone to vasospasm subsequent to surgical manipulation, and application of intra-operative vasodilatory protocols is critical. Post-operative management includes continuation of oral vasodilator therapy and selection of antithrombotic and lipid-lowering agents to attenuate atherosclerotic disease progression in conduits. In this review, the scientific evidence underlying the key aspects of intra- and post-operative management of conduits for coronary artery bypass grafting is examined. Clinical consensus statements for best clinical practice are provided, and areas requiring further research are highlighted.

Sternal Wound Reconstruction Following Deep Sternal Wound Infection: Past, Present and Future: A Literature Review

This literature review critically examines the historical, current, and prospective dimensions of sternal wound reconstruction in the specific context of deep sternal wound infection (DSWI), aiming to enhance patient outcomes and optimise surgical techniques. Preventive measures, including prophylactic antibiotic administration and surgical site preparation, are crucial in reducing the incidence of DSWI. Effective management necessitates a multidisciplinary approach encompassing surgical debridement, drainage, and sternum repair utilising diverse procedures in conjunction with antibiotic therapy. Traditional approaches to managing DSWI involved closed irrigation and drainage techniques. While these methods exhibited certain advantages, they also exhibited limitations and varying degrees of success. The current care paradigms emphasise prophylactic antibiotic administration and surgical interventions like closed suction and irrigation, vacuum-assisted closure, and flap reconstruction. Future advancements in surgical techniques and technology hold promise for further enhancing sternal wound reconstruction. This review separates and emphasises the distinct roles of prophylaxis, antibiotic treatment, and reconstructive techniques, each relevant specifically to DSWI management. Collaborative efforts between cardiac and plastic surgeons, supported by ongoing research and innovation, are indispensable to advance sternal wound restoration and achieve superior outcomes in terms of patient welfare, morbidity and mortality reduction, and surgical efficacy.

Circadian rhythm and daytime variation do not affect intraoperative bacterial sternal contamination and postoperative wound infections following cardiac surgery

Studies have documented various effects of circadian rhythm and daytime variations on the cardiovascular and immune system as well as wound healing. From June to December 2016, n = 367 cardiac surgery patients were enrolled. Microbiological swabs from the mediastinum and subcutaneous wound were taken before sternal closure. Patients were assigned to groups based on operation start: morning (n = 219) or afternoon (n = 135). Bacterial contamination and wound infections were studied in relation to circadian rhythm and daytime variation. We did not observe any difference in mortality (morning: 3.7%, afternoon: 3.0%, p > 0.99) and major adverse events (morning: 8.2%, afternoon: 5.9%, p = 0.53). In 27.7% of the morning group, at least one positive intraoperative swab was observed, similar to the afternoon group (25.6%, p = 0.71). The incidence of positive presternal swabs was 15.6% in the morning compared to 9.1% in the afternoon (p = 0.18). About 90% of the germs detected were part of the natural skin flora (e.g., Cutibacterium acnes and Staphylococcus epidermidis). The incidence of sternal wound infections was 7.3% (morning) and 3.0% (afternoon) (p = 0.18). We did not find differences in the incidence of intraoperative bacterial sternal contamination, nor postoperative infections, between patients who underwent cardiac surgery in the morning or afternoon.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023

OBJECTIVES

Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery.

METHODS

Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type.

RESULTS

Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement.

CONCLUSIONS

Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

Risk factors for sternal wound infection after median sternotomy: A nested case-control study and time-to-event analysis

Although potential risk factors for sternal wound infection (SWI) have been extensively studied, the onset time of SWI and different risk factors for superficial and deep SWI were rarely reported. This nested case-control study aims to compare the onset time and contributors between superficial and deep SWI. Consecutive adult patients who underwent cardiac surgery through median sternotomy in a single center from January 2011 to January 2021 constituted the cohort. The case group was those who developed SWI as defined by CDC and controls were matched 6:1 per case. Kaplan-Meier analysis, LASSO and univariate and multivariate Cox regressions were performed. A simple nomogram was established for clinical prediction of the risk of SWI. The incidence of SWI was 1.1% (61 out of 5471) in our cohort. Totally 366 controls were matched to 61 cases. 26.2% (16 of 61) SWI cases were deep SWI. The median onset time of SWI was 35 days. DSWI had a longer latency than SSWI (median time 46 days vs. 32 days, p = 0.032). Kaplan-Meier analyses showed different time-to-SWI between patients with and without DM (p = 0.0011) or MI (p = 0.0019). Multivariate Cox regression showed that BMI (HR = 1.083, 95% CI: 1.012-1.116, p = 0.022), DM (HR = 2.041, 95% CI: 1.094-3.805, p = 0.025) and MI (HR = 2.332, 95% CI: 1.193-4.557, p = 0.013) were independent risk factors for SWI. Superficial SWI was only associated with BMI (HR = 1.089, 95% CI: 1.01-1.175, p = 0.027), while deep SWI was associated with DM (HR = 3.271, 95% CI: 1.036-10.325, p = 0.043) and surgery time (HR = 1.004, 95% CI: 1.001-1.008, p = 0.027). The nomogram for SWI prediction had an AUC of 0.67, good fitness and clinical effectiveness as shown by the calibration curve and decision curve analyses. BMI, DM and MI were independent risk factors for SWI. DSWI had a longer latency and different risk factors compared to SSWI. The nomogram showed a fair performance and good effectiveness for the clinical prediction of SWI.

Effect of unidirectional airflow ventilation on surgical site infection in cardiac surgery: environmental impact as a factor in the choice for turbulent mixed air flow

BACKGROUND

Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF).

AIM

To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF.

METHODS

This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used.

FINDINGS

Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4-1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA.

CONCLUSION

Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to high electricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgery can diminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

Reducing Sternal Wound Infection Rates in Patients Undergoing Cardiothoracic Surgery with Sternotomy

LOCAL PROBLEM

Sternal wound infections (SWIs), whether superficial or deep, are associated with increased morbidity, mortality, and costs. From 2016 to 2017, our facility saw a 50% decrease in SWIs among patients undergoing cardiothoracic surgery with sternotomy. From 2017 to 2018, however, we identified a 33% increase in SWIs, prompting us to address our cardiac nurses' sternal wound care education and practice.

PURPOSE

The purpose of our quality improvement (QI) project was to identify opportunities for improvement in postoperative sternal incision care and to implement evidence-based processes to reduce the incidence of SWIs among cardiothoracic surgery patients.

METHODS

A literature review was performed to identify interventions focused on evidence-based SWI reduction. During the first quarter of 2019, our postoperative incision care guidelines were revised and released to staff, a new surgical wound cleansing product was supplied, and RN education was provided. Cardiac nurses were surveyed in April 2019 to identify any remaining knowledge and practice deficits and to assess their adherence to the new guidelines. The survey responses helped us to further improve our nurse education. We also provided periodic nurse reeducation and enhanced patient and family education. All such interventions were implemented by the end of June 2019.

RESULTS

Between January and June 2019, we had one SWI. From July 2019 through December 2020, an 18-month period, we experienced zero SWIs. Although beginning in 2021, we saw an increase in SWIs-four in 2021 and five in 2022-our incidence rates remain below 0.5% and we continue to work toward an SWI goal of zero.

CONCLUSION

This QI project identified opportunities for improvement, implemented evidence-based strategies for wound care and education, and successfully achieved a zero SWI rate for a period of 18 months.

Comparative Analysis of Coronary Artery Bypass Grafting Outcomes in Women Using Different Conduits in the National UK Data Set

BACKGROUND

There is limited report of outcomes in women undergoing isolated coronary artery bypass grafting (CABG) with left internal thoracic artery and different second conduits (saphenous vein graft [SVG], radial artery [RA], and right internal thoracic artery [RITA]).

METHODS

The National Adult Cardiac Surgery Audit database was queried for women undergoing isolated CABG with left internal thoracic artery graft in the United Kingdom from 1996 to 2019. Propensity score-based pairwise comparisons were performed between graft types. The primary outcome was in-hospital mortality.

RESULTS

The study included 58,063 women (SVG, n = 48,881 [84.2%]; RA, n = 6136 [10.6%]; RITA, n = 2445 [4.2%]). SVG use was stable over the years; RA and RITA use decreased. In-hospital mortality was similar between the RA and RITA grafts (2.3% vs 2.8%; odds ratio [OR], 0.80; 95% CI, 0.53-1.22; P = .39) and between the RA and SVG (2.3% vs 2.0%; OR, 1.20; 95% CI, 0.93-1.55; P = .17) but higher in the RITA group compared with the SVG (2.7% vs 1.4%; OR, 2.04; 95% CI, 1.27-3.36; P = .004). Women receiving the RITA graft were more likely to have sternal wound infection (SWI) compared with the RA (0.6% vs 0.06%; P = .004) and the SVG (0.6% vs 0.2%; P = .032). SWI was consistently associated with higher risk of in-hospital mortality.

CONCLUSIONS

Conduit selection may affect operative outcomes in women undergoing CABG. The RA shows similar mortality and risk of deep SWI as the SVG.

The negative pressure wound therapy for prevention of sternal wound infection: Can we reduce infection rate after the use of bilateral internal thoracic arteries? A systematic literature review and meta-analysis

BACKGROUND

Negative pressure wound therapy (NPWT) is traditionally used to treat postoperative wound infections. However, its use in closed wound sternotomy post cardiac surgery in high-risk patients has become increasingly popular. The potential preventive benefit of reducing sternal wound infections has been recently acknowledged. Bilateral internal mammary artery (BIMA) grafts are used in coronary artery bypass grafting but have been associated with an increased risk of sternal wound infections (SWIs).

OBJECTIVES

This systematic analysis examines whether NPWT can reduce the incidence of SWI following BIMA grafts, leading to more patients benefiting from the better survival outcome associated with BIMA grafting.

METHOD

A comprehensive systematic search and meta-analysis were performed to identify studies on the use of NPWT in closed wound sternotomy. Ovid MEDLINE (in-process and other nonindexed citations and Ovid MEDLINE 1990 to present), Ovid EMBASE (1990 to present), and The Cochrane Library (Wiley), PubMed, and Google Scholar databases were searched from their inception to May 2022 using keywords and MeSH terms. Thirty-four articles from 1991 to May 2022 were selected.

RESULT

Three studies reported on the outcome of NPWT following BIMA grafting. The pooled analysis did not show any significant difference in the incidence of sternal wound infection between NPWT and standard dressing (RR 0.48 95% CI 0.17-1.37; P = 0.17) with substantial heterogeneity (I2 65%). Another seven studies were found comparing the outcome of SWI incidence of negative pressure closed wound therapy with conventional wound therapy in patients undergoing adult cardiac surgery. The pooled analysis showed that NPWT was associated with a low risk of SWIs compared to conventional dressing (RR 0.47 95% CI 0.36-0.59; P < 0.00001), with low heterogeneity (I2 1%).

CONCLUSION

The literature identified that NPWT significantly decreased the incidence of sternal wound complications when applied to sutured sternotomy incisions in high-risk patients, and in some cases, it eliminated the risk. However, the inadequate number of randomized controlled trials assessing the effectiveness of NPWT in BIMA grafting emphasizes the need for further, robust studies.

Liquid chromatography-tandem mass spectrometry methods for quantification of total and free antibiotic concentrations in serum and exudate from patients with post-sternotomy deep sternal wound infection receiving negative pressure wound therapy

BACKGROUND

Systemically administered antibiotics are thought to penetrate the wounds more effectively during negative pressure wound therapy (NPWT).To test this hypothesis total and free antibiotic concentrations were quantified in serum and wound exudate.

METHODS

UHPLC-MS/MS methods were developed and validated for the determination of ceftazidime, cefepime, cefotaxime, cefuroxime, cefazolin, meropenem, oxacillin, piperacillin with tazobactam, clindamycin, ciprofloxacin, sulfamethoxazole/trimethoprim (cotrimoxazole), gentamicin, vancomycin, and linezolid. The unbound antibiotic fraction was obtained by ultrafiltration using a Millipore Microcon-30kda Centrifugal Filter Unit. Analysis was performed on a 1.7-µm Acquity UPLC BEH C18 2.1 × 100-mm column with a gradient elution.

RESULTS

The validation was performed for serum, exudates and free fractions. For all matrices, requirements were met regarding linearity, precision, accuracy, limit of quantitation, and matrix effect. The coefficient of variation was in the range of 1.2-13.6%.and the recovery 87.6-115.6%, respectively. Among the 29 applications of antibiotics thus far, including vancomycin, clindamycin, ciprofloxacin, oxacillin, cefepime, cefotaxime, cotrimoxazole, and gentamicin, total and free antibiotic concentrations in serum and exudate were correlated.

CONCLUSION

This method can accurately quantify the total and free concentrations of 16 antibiotics. Comparison of concentration ratios between serum and exudates allows for monitoring individual antibiotics' penetration capacity in patients receiving NPWT.

A systematic review and meta-analysis of internal thoracic artery harvesting techniques: Skeletonized vs pedicled

OBJECTIVES

The aim of this meta-analysis was to compare clinical and angiographic outcomes of skeletonized versus pedicled internal thoracic artery for coronary artery bypass grafting.

METHODS

A comprehensive search on Ovid MEDLINE, Ovid EMBASE and Scopus was performed from inception to December 2022. The primary outcome was follow-up mortality and graft failure. Secondary outcomes were repeat revascularization, cardiovascular death and operative mortality, myocardial infarction, stroke, and sternal wound complications (SWCs). Pooled estimate for follow-up outcomes was summarized as incidence rate ratio (IRR) and 95% confidence interval (CI) while short-term outcomes were pooled as odds ratio (OR) and 95% CI. For all outcomes, inverse variance weighting was used for pooling.

RESULTS

Twenty-eight studies, including 7 randomized trials and 21 observational studies, for a total of 5664 patients in the skeletonized group and 7434 in the pedicled group, were included in the analysis. At a mean weighted follow-up of 4.8 years, there was no difference in mortality between the two groups (IRR 1.14; 95% CI 0.59-2.20). However, the skeletonized group had a higher incidence of graft failure compared to the pedicled group (IRR 1.87, 95% CI 1.33-2.63) but a lower risk of SWCs (OR 0.42; 95% CI 0.30-0.60). There was no difference in short-term outcomes.

CONCLUSIONS

Compared to the pedicled harvesting technique, skeletonization of the internal thoracic artery is associated with higher rate of graft failure and lower risk of SWCs without mortality difference.

Immediate flap increases patient safety for deep sternal wound infection: A meta-analysis

Deep sternal wound infection is a severe complication after cardiac surgery. We performed a meta-analysis evaluating the impact of immediate flap and NPWT on mortality and length of hospital stay. The meta-analysis was registered (CRD42022351755). A systematic literature search was conducted from inception to January, 2023, including PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov and EU Clinical Trials Register. The main outcome were in-hospital mortality and late mortality. And additional outcomes were length of stay and ICU stay time. A total of 438 patients (Immediate flap: 229; NPWT: 209) from four studies were included in this study. Immediate flap was associated with lower in-hospital mortality (OR 0.33, 95% CI 0.13-0.81, P = .02) and length of stay (SMD -13.24, 95% CI -20.53 to -5.94, P = .0004). Moreover, pooled analysis demonstrated no significant difference was found in two groups in terms of late mortality (OR 0.64, 95% CI 0.35-1.16, P = .14) and ICU stay time (SMD -1.65, 95% CI -4.13 to 0.83, P = .19). Immediate flap could reduce in-hospital mortality and length of stay for patients with deep sternal wound infection. Flap transplantation as soon as possible may be advised.

Influence and risk factors of postoperative infection after surgery for ischemic cardiomyopathy

Background

Studies on postoperative infection (POI) after surgery for ischemic cardiomyopathy are still lacking. This study aimed to investigate the risk factors of POI and its influence on clinical outcomes in patients undergoing ischemic cardiomyopathy surgery.

Methods

The Surgical Treatment for Ischemic Heart Failure (STICH) trial randomized patients with ischemic cardiomyopathy [coronary artery disease (CAD) with left ventricular ejection fraction ≤35%] to surgical and medical therapy. In this study, a post hoc analysis of the STICH trial was performed to assess the risk factors and clinical outcomes of POI in those undergoing coronary artery bypass graft (CABG). Patients were divided according to whether POI developed during hospitalization or within 30 days from operation.

Results

Of the 2,136 patients randomized, 1,460 patients undergoing CABG per-protocol was included, with a POI rate of 10.2% (149/1,460). By multivariable analysis, POI was significantly related to patients' age, body mass index, depression, chronic renal insufficiency, Duke CAD Index, and mitral valve procedure. Compared to patients without POI, patients with POI had significantly longer durations of intubation, CCU/ICU and hospital stay, and higher rates of re-operation, in-hospital death and failed discharge within 30 days postoperatively. In addition, these patients had significantly higher risks of all-cause death, cardiovascular death, heart failure death, and all-cause hospitalization during long-term follow-up. However, the influence of POI on all-cause death was mainly found during the first year after operation, and the influence was not significant for patients surviving for more than 1 year.

Conclusions

POI was prevalent after surgery for ischemic cardiomyopathy and was closely related to short-term and long-term clinical outcomes, and the effect of POI mainly occurred within the first postoperative year. This study first reported and clarified the relationship between POI and long-term prognosis and the predictors for POI after surgery for ischemic cardiomyopathy worldwide, which may have certain guiding significance for clinical practice.

Clinical Trial Registration

https://www.clinicaltrials.gov, identifier (NCT00023595).

The role of negative pressure wound therapy with instillation and dwell time in the treatment of deep sternal wound infections-A retrospective cohort study

Background and Aims

Negative pressure wound therapy (NPWT) has gained a central role in the treatment of deep sternal wound infections (DSWIs) after median thoracotomy. Our study aims at proving the safety of using NPWT with instillation and dwell time (NPWTi-d) in the treatment of DSWI.

Methods

We retrospectively evaluated the patients who were treated at our institution between March 2018 and November 2021 for DSWI after radical sternectomy using NPWT or NPWTi-d. The NPWTi-d was applied to start the first postoperative day using 75 mmHg negative pressure for 3 h, followed by instillation of sodium hypochlorite <0.08% with a 3-min dwell time.

Results

The NPWTi-d group showed a shorter length of stay (29.39 ± 12.09 vs. 39.54 ± 17.07 days; p = 0.049), a shorter elapsed time between the debridement and the flap coverage (7.18 ± 4.27 vs. 11.86 ± 7.7 days; p = 0.003) and less operative or nonoperative dressing changes (1.73 ± 1.14 vs. 2.68 ± 56; p < 0.001). The in-hospital mortality was 8.2%, with no significant differences between the two groups (p = 1).

Conclusion

NPWTi-d can be safely employed in the treatment of DSWI. Further prospective randomized studies need to establish the role of NPWTi-d in the control of infection and biofilm as well as in wound healing.

Current concepts in coronary artery revascularisation

Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.

Angiographic Outcomes for Arterial and Venous Conduits Used in CABG

Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.

Case Report: Endotracheal tube as life-saving tool to control an aortic rupture in intensive care unit

Background: Aortic rupture and suture dehiscence can complicate a cardiac operation, especially in case of infections of the surgical site. Such a complication can be life-threatening and require immediate surgical treatment. Case: We report the case of a 13-year-old girl who suffered a sudden dehiscence of the aortic suture line in the context of deep sternal wound infection, while in the surgical intensive care unit after a double valve replacement. Control of bleeding was obtained by the insertion of an endotracheal tube into the ascending aorta and inflation of the tube cuff to plug the aortic bleeding point. The extracorporeal circulation was then established and under deep hypothermic arrest the defect was successfully repaired. The patient was discharged 14 days after surgery and reviewed at the outpatient clinic in good health. Conclusions: An endotracheal tube can be used in cases of uncontrollable aortic bleeding as a life-saving tool to bridge the patient to adequate surgical treatment.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis

BACKGROUND

Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes.

METHODS

A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI.

RESULTS

Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01).

CONCLUSION

Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.