Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature

Self-Practice Program for Beating-Heart Minimally Invasive Coronary Anastomosis Using a Homemade Low-Fidelity Simulator: A Proof of Concept

OBJECTIVE

We evaluated the effectiveness of a consistent and structured self-practice coronary anastomosis program using a homemade low-fidelity beating-heart simulator.

METHODS

An intermediary trainee was subjected to an 8-week structured self-practice program. The program was divided into 2 parts of nonbeating and beating practices with a minimum number of timed anastomoses. Each part was followed by an assessment using an objective skills assessment tool score. The beating-heart simulator was built using motorized toy blocks connected wirelessly to a smartphone application. This was coded to enable rate selection. A junior consultant was compared to the subject at the end of the program. Both were tasked to perform 1 coronary anastomosis for both off-pump coronary artery bypass (OPCAB) and minimally invasive CAB (MICS) setup. The primary outcomes were anastomotic time and score compared with the junior consultant. Secondary outcomes were progression of anastomotic time and score throughout the program.

RESULTS

Overall performance of the studied subject approached the performance of the junior consultant in terms of time (OPCAB, 489 vs 605 s; MICS, 712 vs 652 s) and scores (OPCAB, 21 vs 20.7; MICS, 19 vs 20.6). There were inverse correlations between anastomosis time and number of practices for both nonbeating and beating anastomoses. Overall improvement was observed in terms of assessment scoring by 26.6%.

CONCLUSIONS

A structured self-practice program using an affordable and accessible simulator was able to help trainees overcome the MICS anastomosis learning curve quicker when introduced earlier. This may encourage earlier adoption of MICS among surgeons.

Thorax support vest to prevent sternal wound infections in cardiac surgery patients-a systematic review and meta-analysis

OBJECTIVES

Midline sternotomy is the main surgical access for cardiac surgeries. The most prominent complication of sternotomy is sternal wound infection (SWI). The use of a thorax support vest (TSV) that limits thorax movement and ensures sternal stability has been suggested to prevent postoperative SWI.

METHODS

We performed a meta-analysis to evaluate differences in clinical outcomes with and without the use of TSV after cardiac surgery in randomized trials. The primary outcome was deep SWI (DSWI). Secondary outcomes were superficial SWI, sternal wound dehiscence, and hospital length of stay (LOS). A trial sequential analysis was performed. Fixed (F) and random effects (R) models were calculated.

RESULTS

A total of 4 studies (3820 patients) were included. Patients who wore the TSV had lower incidence of DSWI [odds ratio (OR) = F: 0.24, 95% confidence interval (CI), 0.13-0.43, P < 0.01; R: 0.24, 0.04-1.59, P = 0.08], sternal wound dehiscence (OR = F: 0.08, 95% CI, 0.02-0.27, P < 0.01; R: 0.10, 0.00-2.20, P = 0.08) and shorter hospital LOS (standardized mean difference = F: -0.30, -0.37 to -0.24, P < 0.01; R: -0.63, -1.29 to 0.02, P = 0.15). There was no difference regarding the incidence of superficial SWI (OR = F: 0.71, 95% CI, 0.34-1.47, P = 0.35; R: 0.64, 0.10, 4.26, P = 0.42). The trial sequential analysis, however, showed that the observed decrease in DSWI in the TSV arm cannot be considered conclusive based on the existing evidence.

CONCLUSIONS

This meta-analysis suggests that the use of a TSV after cardiac surgery could potentially be associated with a reduction in sternal wound complications. However, despite the significant treatment effect in the available studies, the evidence is not solid enough to provide strong practice recommendations.