Deep sternal wound infection after bilateral internal thoracic artery grafting: Insights from a Japanese national database

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.

Sternal wound infections following internal mammary artery grafts for a coronary bypass: A meta-analysis

The meta-analysis aims to evaluate and compare the sternal wound infections following internal mammary artery grafts for a coronary bypass. Examinations comparing bilateral internal mammary artery to single internal mammary artery for coronary artery bypass grafting were among the meta-analyses from various languages that met the inclusion criteria. Using dichotomous random- or fixed-effect models, the results of these investigations were examined, and the Odd Ratio (OR) with 95% confidence intervals (CIs) was computed. A total of 31 examinations from 2001 to 2023 were recruited for the current analysis including 181 503 personals with coronary artery bypass grafting. Bilateral internal mammary artery had significantly higher sternal wound infection (OR, 1.51; 95% CI, 1.37-1.68, p < 0.001), superficial sternal wound infection (OR, 1.72; 95% CI, 1.16-2.56, p = 0.007), deep sternal wound infection (OR, 1.62; 95% CI, 1.41-1.86, p < 0.001), sternal wound infection in diabetics (OR, 1.48; 95% CI, 1.16-1.90, p = 0.002), sternal wound infection in elderly (OR, 1.38; 95% CI, 1.22-1.57, p < 0.001), sternal wound infection in pedicled preparation (OR, 1.70; 95% CI, 1.30-2.23, p < 0.001) and sternal wound infection in skeletonized preparation (OR, 1.40; 95% CI, 1.09-1.81, p = 0.009) compared to single internal mammary artery in personals with coronary artery bypass grafting. Bilateral internal mammary artery grafting is linked to a higher risk of impaired wound healing, particularly in diabetic individuals, elderly, pedicled preparation, and skeletonized preparation. Nevertheless, caution should be exercised while interacting with its values since examinations were performed by different surgeons with different skills on different types of personals.

Strategies to Minimize Sternal and Leg Wound Complications after Coronary Artery Bypass Grafting Using No-Touch Saphenous Vein Grafts

PURPOSE

The aims of the present study were to examine sternal and saphenous vein (SV) harvest site wound complication rates, and to assess the strategies to minimize the sternal and leg wound complications after coronary artery bypass grafting using a no-touch (NT) SV.

METHODS

Patients who underwent coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) and/or NT SV grafts from March 2021 to June 2023 (N = 166) at a newly opened cardiac surgical program were included. We obeyed the current guidelines for the prevention of sternal wound infection. In addition, unilateral ITA was used in most of the patients and the sternal wound was meticulously closed using multiple sternal wires (≥7) and ZipFix. For the NT SV harvesting, the LigaSure device was used to minimize thermal injury, and the wound was meticulously closed.

RESULTS

Sternal wound infections developed in 3/166 (1.8%) patients; all three patients showed superficial sternal wound infections. Leg wound complications were present in 2/153 (1.3%) patients, who recovered after secondary intention healing.

CONCLUSION

Sternal wound complications after CABG could be minimized by the unilateral ITA usage, meticulous closure of the sternal wound in addition to compliance with the current guidelines. Wound complications after NT SV harvest may also be minimized by preoperative evaluation, careful harvesting, and meticulous wound closure.

Risk factors for sternal wound infection after open-heart operations: A systematic review and meta-analysis

We aimed to quantitatively and systematically elucidate the rationality of the examined variables as independent risk factors for sternal wound infection. We searched databases to screen studies, ascertained the variables to be analysed, extracted the data and applied meta-analysis to each qualified variable. Odds ratios and mean differences were considered to be the effect sizes for binary and continuous variables, respectively. A random-effects model was used for these procedures. The source of heterogeneity was evaluated using a meta-regression. Publication bias was tested by funnel plot and Egger's test, the significant results of which were then calculated using trim and fill analysis. We used a sensitivity analysis and bubble chart to describe their robustness. After screening all variables in the eligible literature, we excluded 55 because only one or no research found them significant after multivariate analysis, leaving 33 variables for synthesis. Two binary variables (age over 65 years, NYHA class >2) and a continuous variable (preoperative stay) were not significant after the meta-analysis. The most robust independent risk factors in our study were diabetes mellitus, obesity, use of bilateral internal thoracic arteries, chronic obstructive pulmonary disease, prolonged surgery time, prolonged ventilation and critical preoperative state, followed by congestive heart failure, atrial fibrillation, renal insufficiency, stroke, peripheral vascular disease and use of an intra-aortic balloon pump. Relatively low-risk factors were emergent/urgent surgery, smoking, myocardial infarction, combined surgery and coronary artery bypass grafting. Sternal wound infection after open-heart surgery is a multifactorial disease. The detected risk factors significantly affected the wound healing process, but some were different in strength. Anything that affects wound healing and antibacterial ability, such as lack of oxygen, local haemodynamic disorders, malnutrition condition and compromised immune system will increase the risk, and this reminds us of comprehensive treatment during the perioperative period.

Mechanical vs Bioprosthetic Aortic Valve Replacement in Patients on Dialysis: Long-term Outcomes

BACKGROUND

Using the Japan National Clinical Database and additional data, this study is an analysis of long-term survival of dialysis-dependent patients who underwent aortic valve replacement (AVR).

METHODS

Dialysis-dependent patients who underwent de novo AVR between 2010 and 2012 and who were registered in the database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. Additional data on the underlying kidney disease, the duration of dialysis, and clinical outcomes were registered between October 29, 2019, and August 30, 2020. The primary outcome was all-cause mortality. The secondary outcomes were cerebral infarction, cerebral bleeding, gastrointestinal bleeding, and prosthetic valve failure.

RESULTS

After propensity score matching, 1016 cases (508 each in the bioprosthetic and mechanical valve groups) were matched. The median follow-up period was 3.29 years (interquartile range [IQR], 0.59 years, 6.25 years). The median survival time was 5.38 years (IQR, 1.20 and 9.26 years) in the mechanical valve group and 4.98 years (IQR, 1.69 and 9.62 years) in the bioprosthetic valve group. The Cox regression model showed no significant difference in long-term survival between the groups (mechanical valve: hazard ratio [HR], 0.895; 95% CI, 0.719-1.113; P = .318). The incidences of cerebral infarction and prosthetic valve failure requiring admission were similar between the groups. Cerebral bleeding (HR, 2.143; 95% CI, 1.125-4.080; P = .002) and gastrointestinal bleeding (HR, 2.071; 95% CI, 1.243-3.451; P = .0005) were more frequent in the mechanical valve group.

CONCLUSIONS

Long-term survival of dialysis-dependent patients was similar regardless of whether mechanical valves or bioprosthetic valves were implanted. The incidences of cerebral and gastrointestinal bleeding were 2-fold higher in the mechanical valve group.

Surgical Site Infection in Cardiac Surgery

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

Performance of a novel risk model for deep sternal wound infection after coronary artery bypass grafting

Clinical prediction models for deep sternal wound infections (DSWI) after coronary artery bypass graft (CABG) surgery exist, although they have a poor impact in external validation studies. We developed and validated a new predictive model for 30-day DSWI after CABG (REPINF) and compared it with the Society of Thoracic Surgeons model (STS). The REPINF model was created through a multicenter cohort of adults undergoing CABG surgery (REPLICCAR II Study) database, using least absolute shrinkage and selection operator (LASSO) logistic regression, internally and externally validated comparing discrimination, calibration in-the-large (CL), net reclassification improvement (NRI) and integrated discrimination improvement (IDI), trained between the new model and the STS PredDeep, a validated model for DSWI after cardiac surgery. In the validation data, c-index = 0.83 (95% CI 0.72–0.95). Compared to the STS PredDeep, predictions improved by 6.5% (IDI). However, both STS and REPINF had limited calibration. Different populations require independent scoring systems to achieve the best predictive effect. The external validation of REPINF across multiple centers is an important quality improvement tool to generalize the model and to guide healthcare professionals in the prevention of DSWI after CABG surgery.

Evaluation of the Effect of Comprehensive and Targeted Surveillance on Nosocomial Infections in Nephrology Patients

The article summarizes the control strategy by discussing the risk factors of nosocomial infections in the nephrology department. A survey of hospitalized patients from January 2020 to December 2020 showed that there are six types of bacteria that can cause infections. The age of the patient, the risk of invasive surgery, the low use of antibiotics, and age are all independent factors that affect the risk of nosocomial infections in the patient. The more antibiotics used, the better the infection prevention effect. Among the many risk factors for patient infection, bacterial infection is the main risk factor. Klebsiella pneumoniae infection rate was the highest, 33.98%; Staphylococcus aureus infection rate was the lowest, 6.80%. Therefore, the nephrology department should focus on strengthening the prevention of Klebsiella pneumoniae infection, and implement early prevention and management interventions for various risk factors.

An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience

Background Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.

Methods A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.

Results One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5–15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).

Conclusion Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.

Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature

Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.

•

Bilateral internal thoracic artery grafting is superior to single internal thoracic artery grafting in terms of outcomes.

•

Bilateral internal thoracic artery grafting is underused, especially in diabetic patients.

•

The risk of DSWI in skeletonized BITA grafting in diabetic patients is almost similar to SITA grafting.

•

Skeletonized BITA grafting should be encouraged in selected diabetic patients.

[Early and long-term outcomes of bilateral inthernal thoracic artery grafting for coronary artery bypass surgery]

OBJECTIVE

To evaluate safety of coronary artery bypass surgery using bilateral internal mammary artery and effectiveness of this procedure in long-term postoperative period.

MATERIAL AND METHODS

The study involved 129 patients who underwent CABG for the period 2006-2007. There were 2 groups of patients depending on surgical strategy: group 1 (n=61) - double IMA harvesting, group 2 (n=68) - CABG using single IMA. Short-term results were compared using standard statistical methods. Long-term survival was compared using Kaplan-Meyer method.

RESULTS

Revascularization index was 3.014±0.76 in the 1st group and 3.1±0.73 in the 2nd group (p>0.05). In-hospital mortality was 0% and 1.47%, respectively (p> 0.05). A 10-year survival was 95.1% and 91.2%, respectively (p>0.05). Freedom from cardiac events (mortality, myocardial infarction, recurrent angina pectoris) was significantly different (95% vs. 81%, p<0.05).

CONCLUSION

Significantly lower rate of adverse cardiac events in long-term postoperative period in comparison with conventional CABG clearly demonstrates high quality of life after coronary artery bypass surgery using bilateral internal mammary artery for a long time. Therefore, this procedure is preferred in patients with coronary artery disease.