1
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Ivert T, Berge A, Bratt S, Dalén M. Incidence and healing times of postoperative sternal wound infections: a retrospective observational single-centre study. SCAND CARDIOVASC J 2024; 58:2330349. [PMID: 38500294 DOI: 10.1080/14017431.2024.2330349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/28/2023] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Objectives: Analyses of incidence and time required to heal sternal wound infections after heart surgery performed via a median sternotomy between 2020 and 2022. Results: Superficial wound infections (SWI) were five times more common (2.7%) than mediastinitis (0.5%) among 2693 patients. The median time between the operation and diagnosis of SWI was 26 (interquartile range [IQR] 15-33) days vs. 16 (IQR 9-25) days for mediastinitis (p = .12). Gram-negative bacteria caused 44% of the 85 infections. Sternal wound infection correlated to higher body mass index, female sex, smoking, diabetes mellitus, previous myocardial infarction, coronary artery bypass grafting, use of internal mammary graft, and re-entry for postoperative bleeding. Eight of 59 patients (13.6%) with sternal wound infections had bilateral mammary grafts, compared to 102 of 1191 patients (8.6%) without wound infections (p = .28). Negative pressure wound therapy was always used to treat mediastinitis and applied in 63% of patients with SWI. Two of 13 patients with mediastinitis (15%) and none of 72 patients with SWI died within 90 days after the operation. The median time until the wound healed was 1.9 (IQR 1.3-3.7) months after SWI vs. 1.7 (IQR 1.3-5.3) months after mediastinitis (p = .63). Six patients (7%) required longer than one year to treat the infection. Conclusions: Postoperative sternal wound infections usually appeared several weeks after surgery and were associated with factors as high body mass index, diabetes mellitus and coronary artery bypass. SWI were more common than mediastinitis and often required negative pressure wound therapy and similar treatment time as mediastinitis.
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Affiliation(s)
- Torbjörn Ivert
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Andreas Berge
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sorosh Bratt
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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2
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Vinokurov IA, Belov YV, Tagabilev DG, Yusupov SA. [Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. Khirurgiia (Mosk) 2024:78-84. [PMID: 39008700 DOI: 10.17116/hirurgia202407178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
OBJECTIVE To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.
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Affiliation(s)
- I A Vinokurov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - Yu V Belov
- Petrovsky National Research Center of Surgery, Moscow, Russia
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - D G Tagabilev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - S A Yusupov
- Petrovsky National Research Center of Surgery, Moscow, Russia
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3
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Braun C, Schroeter F, Laux ML, Kuehnel RU, Ostovar R, Hartrumpf M, Necaev AM, Sido V, Albes JM. The Impact of Gender and Age in Obese Patients on Sternal Instability and Deep-Sternal-Wound-Healing Disorders after Median Sternotomy. J Clin Med 2023; 12:4271. [PMID: 37445306 DOI: 10.3390/jcm12134271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between age and sex in regard to the development of deep sternal wound infections and sternal instability following median sternotomy. METHODS A propensity-score-matching analysis was conducted on 4505 patients who underwent cardiac surgery between 2009 and 2021, all of whom had a BMI of ≥30 kg/m2. A total of 1297 matched pairs were determined in the sex group, and 1449 matched pairs we determined in the age group. The distributions of sex, age, diabetes mellitus, delirium, unstable sterna, wire refixation, wire removal, superficial vacuum-assisted wound closure, deep vacuum-assisted wound closure, clamp time, bypass time, logistic EuroSCORE, and BMI were determined. RESULTS The 30-day in-hospital mortality was found to be similar in the older and younger groups (8.149% vs. 8.35%, p = 0.947), and diabetes mellitus was also equally distributed in both groups. However, postoperative delirium occurred significantly more often in the older group (29.81% vs. 17.46%, p < 0.001), and there was a significantly higher incidence in men compared with women (16.96% vs. 26.91%, p < 0.001). There were no differences found in the incidence of sternum instability, fractured sternum, superficial vacuum-assisted wound closure, and deep vacuum-assisted wound closure between the age and sex groups. CONCLUSIONS In conclusion, this study found that sternal instability and deep-wound-healing problems occur with equal frequency in older and younger patients and in men and women following median sternotomy. However, the likelihood of postoperative delirium is significantly higher in older patients and in men. These findings suggest that a higher level of monitoring and care may be required for these high-risk patient groups to reduce the incidence of postoperative delirium and improve outcomes following median sternotomy.
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Affiliation(s)
- Christian Braun
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Filip Schroeter
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Magdalena Lydia Laux
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Ralf-Uwe Kuehnel
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Roya Ostovar
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Martin Hartrumpf
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Anna-Maria Necaev
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Viyan Sido
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
| | - Johannes Maximilian Albes
- Department of Cardiovascular Surgery, Heart Center Brandenburg, Faculty of Health Sciences Brandenburg, University Hospital Brandenburg Medical School "Theodor Fontane", Ladeburger Str. 17, 16321 Bernau bei Berlin, Germany
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The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis. Plast Reconstr Surg Glob Open 2022; 10:e4233. [PMID: 35506023 PMCID: PMC9053136 DOI: 10.1097/gox.0000000000004233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
Abstract
Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.
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5
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Kaspersen AE, Nielsen SJ, Orrason AW, Petursdottir A, Sigurdsson MI, Jeppsson A, Gudbjartsson T. Short- and long-term mortality after deep sternal wound infection following cardiac surgery: experiences from SWEDEHEART. Eur J Cardiothorac Surg 2021; 60:233-241. [PMID: 33623983 DOI: 10.1093/ejcts/ezab080] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Deep sternal wound infection (DSWI) is a serious complication after open-heart surgery. We investigated the association between DSWI and short- and long-term all-cause mortality in a large well-defined nationwide population. METHODS A retrospective, nationwide cohort study, which included 114676 consecutive patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery from 1997 to 2015 in Sweden. Short- and long-term mortality was compared between DSWI patients and non-DSWI patients using propensity score inverse probability weighting adjustment based on patient characteristics and comorbidities. Median follow-up was 8.0 years (range 0-18.9). RESULTS Altogether, 1516 patients (1.3%) developed DSWI, most commonly in patients undergoing combined CABG and valve surgery (2.1%). DSWI patients were older and had more disease burden than non-DSWI patients. The unadjusted cumulative mortality was higher in the DSWI group compared with the non-DSWI group at 90 days (7.9% vs 3.0%, P < 0.001) and at 1 year (12.8% vs 4.5%, P < 0.001). The adjusted absolute difference in risk of death was 2.3% [95% confidence interval (CI): 0.8-3.9] at 90 days and 4.7% (95% CI: 2.6-6.7) at 1 year. DSWI was independently associated with 90-day [adjusted relative risk (aRR) 1.89 (95% CI: 1.38-2.59)], 1-year [aRR 2.13 (95% CI: 1.68-2.71)] and long-term all-cause mortality [adjusted hazard ratio 1.56 (95% CI: 1.30-1.88)]. CONCLUSIONS Both short- and long-term mortality risks are higher in DSWI patients compared to non-DSWI patients. These results stress the importance of preventing these infections and careful postoperative monitoring of DSWI patients.
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Affiliation(s)
- Alexander Emil Kaspersen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Susanne J Nielsen
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | | - Astridur Petursdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin Ingi Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Anaesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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6
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Kachel E, Moshkovitz Y, Sternik L, Sahar G, Grosman-Rimon L, Belotserkovsky O, Reichart M, Stark Y, Emanuel N. Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology. J Card Surg 2020; 35:2695-2703. [PMID: 32743813 DOI: 10.1111/jocs.14890] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sternal wound infection (SWI) is a devastating postcardiac surgical complication. D-PLEX100 (D-PLEX) is a localized prolonged release compound applied as a prophylactic at the completion of surgery to prevent SWI. The D-PLEX technology platform is built as a matrix of alternating layers of polymers and lipids, entrapping an antibiotic (doxycycline). The objective of this study was to assess the safety profile and pharmacokinetics of D-PLEX in reducing SWI rates postcardiac surgery. METHOD Eighty-one patients were enrolled in a prospective single-blind randomized controlled multicenter study. Sixty patients were treated with both D-PLEX and standard of care (SOC) and 21 with SOC alone. Both groups were followed 6 months for safety endpoints. SWI was assessed at 90 days. RESULTS No SWI-related serious adverse events (SAEs) occurred in either group. The mean plasma Cmax in patients treated with D-PLEX was about 10 times lower than the value detected following the oral administration of doxycycline hyclate with an equivalent overall dose, and followed by a very low plasma concentration over the next 30 days. There were no sternal infections in the D-PLEX group (0/60) while there was one patient with a sternal infection in the control group (1/21, 4.8%). CONCLUSION D-PLEX was found to be safe for use in cardiac surgery patients. By providing localized prophylactic prolonged release of broad-spectrum antibiotics, D-PLEX has the potential to prevent SWI postcardiac surgery and long-term postoperative hospitalization, reducing high-treatment costs, morbidity, and mortality.
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Affiliation(s)
- Erez Kachel
- Department of Cardiac Surgery, Poriya Medical Center, Tiberias, Israel.,Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Yaron Moshkovitz
- Department of Cardiothoracic Surgery, Assuta Medical Center, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Gideon Sahar
- Department of Cardiothoracic Surgery, Soroka Medical Center, Beer Sheva, Israel
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7
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Preoperative risk stratification of deep sternal wound infection after coronary surgery. Infect Control Hosp Epidemiol 2020; 41:444-451. [PMID: 31957634 DOI: 10.1017/ice.2019.375] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop a risk score for deep sternal wound infection (DSWI) after isolated coronary artery bypass grafting (CABG). DESIGN Multicenter, prospective study. SETTING Tertiary-care referral hospitals. PARTICIPANTS The study included 7,352 patients from the European multicenter coronary artery bypass grafting (E-CABG) registry. INTERVENTION Isolated CABG. METHODS An additive risk score (the E-CABG DSWI score) was estimated from the derivation data set (66.7% of patients), and its performance was assessed in the validation data set (33.3% of patients). RESULTS DSWI occurred in 181 (2.5%) patients and increased 1-year mortality (adjusted hazard ratio, 4.275; 95% confidence interval [CI], 2.804-6.517). Female gender (odds ratio [OR], 1.804; 95% CI, 1.161-2.802), body mass index ≥30 kg/m2 (OR, 1.729; 95% CI, 1.166-2.562), glomerular filtration rate <45 mL/min/1.73 m2 (OR, 2.410; 95% CI, 1.413-4.111), diabetes (OR, 1.741; 95% CI, 1.178-2.573), pulmonary disease (OR, 1.935; 95% CI, 1.178-3.180), atrial fibrillation (OR, 1.854; 95% CI, 1.096-3.138), critical preoperative state (OR, 2.196; 95% CI, 1.209-3.891), and bilateral internal mammary artery grafting (OR, 2.088; 95% CI, 1.422-3.066) were predictors of DSWI (derivation data set). An additive risk score was calculated by assigning 1 point to each of these independent risk factors for DSWI. In the validation data set, the rate of DSWI increased along with the E-CABG DSWI scores (score of 0, 1.0%; score of 1, 1.8%; score of 2, 2.2%; score of 3, 6.9%; score ≥4: 12.1%; P < .0001). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed that the E-CABG DSWI score performed better than other risk scores. CONCLUSIONS DSWI is associated with poor outcome after CABG, and its risk can be stratified using the E-CABG DSWI score. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02319083.
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8
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Abdelnoor M, Sandven I, Vengen Ø, Risnes I. Mediastinitis in open heart surgery: a systematic review and meta-analysis of risk factors. SCAND CARDIOVASC J 2019; 53:226-234. [PMID: 31290699 DOI: 10.1080/14017431.2019.1642508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 06/18/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
Objective. We aimed to summarize the evidence from observational studies examining the risk factors of the incidence of mediastinitis in open heart surgery. Design. The study was a systematic review and meta-analysis of cohorts and case-control studies. Material and methods. We searched the literature and 74 studies with at least one risk factor were identified. Both fixed and random effects models were used. Heterogeneity between studies was examined by subgroup and meta-regression analysis. Publication bias or small study effects were evaluated and corrected by limit meta-analysis. Results. When correcting for small study effect, presence of obesity as estimated from 43 studies had Odds Ratio OR = 2.26. (95% CI: 2.17-2.36). This risk was increasing with decreasing latitude of study place. Presence of diabetes mellitus from 63 studies carried an OR = 1.90 (95% CI: 1.59-2.27). Presence of Chronic Obstructive Pulmonary Disease (COPD) from 30 studies had an OR = 2.59 (95% CI: 2.22-2.85). Presence of bilateral intramammary graft (BIMA) from 23 studies carried an OR = 2.54 (95% CI: 2.07-3.13). This risk was increasing with increasing frequency of female patients in the study population. Conclusion. Evidence from this study showed the robustness of the risk factors in the pathogenesis of mediastinitis. Preventive measures can be implemented for reducing obesity, especially in lower latitude countries. Furthermore, it is mandatory to monitor perioperative hyperglycemias with continuous insulin infusion. Use of skeletonized BIMA carries higher risk of mediastinitis especially in female patients without evidence of beneficial effect on survival for the time being.
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Affiliation(s)
- Michael Abdelnoor
- Centre of Clinical Heart Research, Oslo University Hospital , Oslo , Norway
- Epidemiology and Biological Statistics, Independent Health Research Unit , Oslo , Norway
| | - Irene Sandven
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital , Oslo , Norway
| | - Øystein Vengen
- Department of Cardiovascular Surgery, Oslo University Hospital , Oslo , Norway
| | - Ivar Risnes
- Department of Cardiovascular Surgery, Oslo University Hospital , Oslo , Norway
- Department of Cardiovascular Surgery, LHL Hospital , Gardemoen , Norway
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9
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Al-Harbi SA, Alkhayal N, Alsehali A, Alshaya S, Bin Obaid W, Althubaiti A, van Onselen RE, Al Annany M, Arifi AA. Impact of blood transfusion on major infection after isolated coronary artery bypass surgery: Incidence and risk factors. J Saudi Heart Assoc 2019; 31:254-260. [PMID: 31388291 PMCID: PMC6669374 DOI: 10.1016/j.jsha.2019.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
Abstract
Background/aim Cardiac surgery is considered one of the conditions that require a transfusion of blood and blood products in large amount. Infections are one of the most common complications after cardiac surgery. The aim of this study is to assess the impact of blood transfusion on major infections after isolated coronary artery bypass surgery (CABG). Methods A retrospective cohort study was conducted at King Abdulaziz Cardiac Center. Eligible adult patients, aged >18 years, who underwent an isolated CABG from 2015 to 2016, were included. Patient demographic information, as well as pre-, intra-, and postoperative data were collected from the electronic hospital information system charts and perfusion records. For data analysis, categorical pre- and postoperative variables were summarized by frequencies and percentages, whereas for continuous variables, means and standard deviation or median and interquartile ranges were used. Results The sample size was 459 patients. Red blood cells (RBCs) were transfused in 60.1% of the patients, and the median number of units transfused per patient was 2. The mean hemoglobin threshold for transfusion was 8.2 (standard deviation ± 3.6) g/dL. The mean EuroSCORE of RBC recipients was 3.8 ± 5.9% and that of non-RBC recipients was 2.0 ± 2.0%. In both groups (RBC recipients and non-RBC recipients), the most frequent infections after CABG were pneumonia (12% and 8.7%, respectively), deep surgical site infection (3.6% and 0.5%, respectively), and superficial sternal infection (6.9% and 3.8%, respectively), with a statistically significant difference (all p < 0.05). Patients receiving a blood transfusion at any stage during the intraoperative or postoperative period were 2.6 times more likely to develop an infection compared with those who did not receive a blood transfusion. The recipients of a blood transfusion experienced a longer hospital stay compared with the non-recipients at 11.5 ± 9.8 days versus 8.7 ± 3.4 days, respectively. Conclusions Blood transfusion appears to increase the risk of infection post-CABG. However, increased understanding of the role of other potential clinical confounding variables that may impact the infection rate is required. We recommend management strategies that limit RBC transfusion.
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Affiliation(s)
- Shaikhah Awadh Al-Harbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Noura Alkhayal
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Afrah Alsehali
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Shatha Alshaya
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Wesam Bin Obaid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia
| | - Alaa Althubaiti
- King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia.,Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia
| | - R E van Onselen
- King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia.,Cardiac Clinical Research, Cardiac Surgery, Cardiac Sciences, King Abdulaziz Cardiac Center, Ministry of National Guard, Riyadh, Saudi ArabiaSaudi Arabia
| | - Mohmed Al Annany
- Cardiac Clinical Research, Cardiac Surgery, Cardiac Sciences, King Abdulaziz Cardiac Center, Ministry of National Guard, Riyadh, Saudi ArabiaSaudi Arabia.,Ain Shams University Cario, EgyptEgypt
| | - Ahmed A Arifi
- King Abdullah International Medical Research Center, Riyadh, Saudi ArabiaSaudi Arabia.,Cardiac Clinical Research, Cardiac Surgery, Cardiac Sciences, King Abdulaziz Cardiac Center, Ministry of National Guard, Riyadh, Saudi ArabiaSaudi Arabia
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10
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Ruzmatov TM, Zheravin AA, Doronin DV, Tarkova AR, Nesmachny AS, Chernyavsky AM. [Sternomediastinitis after cardiac transplantation]. Khirurgiia (Mosk) 2017:77-81. [PMID: 29186102 DOI: 10.17116/hirurgia20171177-81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- T M Ruzmatov
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A A Zheravin
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - D V Doronin
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A R Tarkova
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A S Nesmachny
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A M Chernyavsky
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
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11
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Hematological predictors and clinical outcomes in cardiac surgery. J Anesth 2016; 30:770-8. [DOI: 10.1007/s00540-016-2197-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
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12
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Abdelnoor M, Vengen ØA, Johansen O, Sandven I, Abdelnoor AM. Latitude of the study place and age of the patient are associated with incidence of mediastinitis and microbiology in open-heart surgery: a systematic review and meta-analysis. Clin Epidemiol 2016; 8:151-163. [PMID: 27330329 PMCID: PMC4898030 DOI: 10.2147/clep.s96107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We aimed to summarize the pooled frequency of mediastinitis following open-heart surgery caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria. DESIGN This study was a systematic review and a meta-analysis of prospective and retrospective cohort studies. MATERIALS AND METHODS We searched the literature, and a total of 97 cohort studies were identified. Random-effect model was used to synthesize the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses, considering study and patient-level variables. Small-study effect was evaluated. RESULTS Substantial heterogeneity was present. The estimated incidence of mediastinitis evaluated from 97 studies was 1.58% (95% confidence intervals [CI] 1.42, 1.75) and that of Gram-positive bacteria, Gram-negative bacteria, and MRSA bacteria evaluated from 63 studies was 0.90% (95% CI 0.81, 1.21), 0.24% (95% CI 0.18, 0.32), and 0.08% (95% CI 0.05, 0.12), respectively. A meta-regression pinpointed negative association between the frequency of mediastinitis and latitude of study place and positive association between the frequency of mediastinitis and the age of the patient at operation. Multivariate meta-regression showed that prospective cohort design and age of the patients and latitude of study place together or in combination accounted for 17% of heterogeneity for end point frequency of mediastinitis, 16.3% for Gram-positive bacteria, 14.7% for Gram-negative bacteria, and 23.3% for MRSA bacteria. CONCLUSION Evidence from this study suggests the importance of latitude of study place and advanced age as risk factors of mediastinitis. Latitude is a marker of thermally regulated bacterial virulence and other local surgical practice. There is concern of increasing risk of mediastinitis and of MRSA in elderly patients undergoing sternotomy.
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Affiliation(s)
- M Abdelnoor
- Centre for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Ø A Vengen
- Department of Cardiovascular Surgery, Oslo University Hospital, Oslo, Norway
| | - O Johansen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - I Sandven
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - AM Abdelnoor
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon
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Meszaros K, Fuehrer U, Grogg S, Sodeck G, Czerny M, Marschall J, Carrel T. Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation. Ann Thorac Surg 2015; 101:1418-25. [PMID: 26652136 DOI: 10.1016/j.athoracsur.2015.09.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.
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Affiliation(s)
- Katharina Meszaros
- Department for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland; Department for General Surgery, Medical University of Graz, Graz, Austria
| | - Urs Fuehrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sina Grogg
- Department for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Gottfried Sodeck
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Martin Czerny
- Department for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department for Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland.
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Comparison of Efficacy and Cost of Iodine Impregnated Drape vs. Standard Drape in Cardiac Surgery: Study in 5100 Patients. J Cardiovasc Transl Res 2015; 8:431-7. [DOI: 10.1007/s12265-015-9653-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
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Bejko J, Bottio T, Tarzia V, De Franceschi M, Bianco R, Gallo M, Castoro M, Bortolussi G, Gerosa G. Nitinol flexigrip sternal closure system and standard sternal steel wiring. J Cardiovasc Med (Hagerstown) 2015; 16:134-8. [DOI: 10.2459/jcm.0000000000000025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Sharma M, Berriel-Cass D, Baran J. Sternal Surgical-Site Infection Following Coronary Artery Bypass Graft Prevalence, Microbiology, and Complications During a 42-Month Period. Infect Control Hosp Epidemiol 2015; 25:468-71. [PMID: 15242193 DOI: 10.1086/502423] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractObjective:Surgical-site infection (SSI) is a serious and costly complication following coronary artery bypass graft (CABG). We analyzed surgical factors, microbiology, and complications at a 608-bed community teaching hospital to identify opportunities for prevention.Methods:All patients undergoing CABG procedures from June 1997 through December 2000 were analyzed. Hospital records and postdischarge surveillance data were reviewed for demographics, surgical information, timing and classification of infection, microbiology, and bacteremic events.Results:Of 3,443 patients undergoing CABG, sternal SSI developed in 122 (3.5%); 71 (58.2%) were classified as superficial SSI and 51 (41.8%) as deep SSI. Surgical antimicrobial prophylaxis was employed in all cases. On average, infection occurred 21.5 days (range, 4 to 315) after CABG. Most cases were diagnosed on readmission (59%); 20 cases (16%) were identified by postdischarge surveillance. Microbiological data were positive in 109 (89.3%), with a single pathogen implicated in most (86.2%). Gram-positive cocci were most frequently recovered (81%); gram-negative bacilli (17%), gram-positive bacilli (1%), and yeast (1%) were less common.Staphylococcus aureuswas the most frequently isolated pathogen (49%). Bacteremia was noted in 22 instances (18%). It was significantly associated with deep SSI (P=. 002) and identified only inS. aureuscases.Conclusions:SSI complicated 3.5% of the procedures.S. aureuswas implicated in most of the cases and was significantly associated with deep SSI. It was the only pathogen associated with secondary bacteremia. In addition to standard guidelines, targeted methods againstS. aureusshould help reduce the overall rate of SSI.
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Affiliation(s)
- Mamta Sharma
- Department of Internal Medicine, Division of Infectious Diseases, St. John Hospital and Medical Center, 22101 Moross Road, Detroit, MI 48236, USA
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17
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Coronary artery bypass graft surgery: the past, present, and future of myocardial revascularisation. Surg Res Pract 2014; 2014:726158. [PMID: 25374960 PMCID: PMC4208586 DOI: 10.1155/2014/726158] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 07/25/2013] [Indexed: 11/18/2022] Open
Abstract
The development of the heart-lung machine ushered in the era of modern cardiac surgery. Coronary artery bypass graft surgery (CABG) remains the most common operation performed by cardiac surgeons today. From its infancy in the 1950s till today, CABG has undergone many developments both technically and clinically. Improvements in intraoperative technique and perioperative care have led to CABG being offered to a more broad patient profile with less complications and adverse events. Our review outlines the rich history and promising future of myocardial revascularization.
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Tschudin-Sutter S, Meinke R, Schuhmacher H, Dangel M, Eckstein F, Reuthebuch O, Widmer AF. Drainage days-an independent risk factor for serious sternal wound infections after cardiac surgery: a case control study. Am J Infect Control 2013; 41:1264-7. [PMID: 23870294 DOI: 10.1016/j.ajic.2013.03.311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative sternal wound infections are a potentially devastating complication following cardiac surgery. The aim of our study was to determine risk factors associated with patients' baseline characteristics and peri- and postoperative management for the development of surgical site infections (SSIs) after cardiac surgery involving sternotomy. METHODS Since 2009 the University Hospital of Basel, a tertiary care center in Switzerland, has participated in the national SSI-surveillance program by conducting postdischarge surveillance. We conducted a nested case-control study involving 30 consecutive patients with an organ/space SSI after cardiac surgery and 60 control patients. RESULTS Receipt of antibiotics before operation (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.41; P = .032), decreased albumin levels (OR, 0.87; 95% CI, 0.76-0.99; P = .040, respectively), time on extracorporal circulation (OR, 1.02; 95% CI, 1.00-1.03; P = .012), number of drainages (OR, 9.15; 95% CI, 2.01-41.76; P = .004), length of drain retention (OR, 1.44; 95% CI, 1.10-1.90; P = .009), and resuscitation (OR, 7.30; 95% CI, 1.53-34.71; P = .012) were associated with SSIs. Incidence density drainage days-accounting for both number of drains and length of retention-were the only independent risk factor (OR, 1.12; 95% CI, 1.02-1.11; P = .018). CONCLUSIONS Retention of drainages in the operative site longer than 48 hours was the only independent risk factor for the development of organ/space sternal wound infections after cardiac surgery.
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Affiliation(s)
- Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, Basel, Switzerland
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Aigner P, Eskandary F, Schlöglhofer T, Gottardi R, Aumayr K, Laufer G, Schima H. Sternal force distribution during median sternotomy retraction. J Thorac Cardiovasc Surg 2013; 146:1381-6. [PMID: 24075560 DOI: 10.1016/j.jtcvs.2013.07.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 07/12/2013] [Accepted: 07/26/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Median sternotomy is the access of choice in cardiac surgery. Sternal retractors exert significant forces on the thoracic cage and might cause considerable damage. The aim of this study was to determine the effects of retractor shape on local force distribution to obtain criteria for retractor design. METHODS Two types of sternal retractors (straight [SSR] and curved [CSR]) were equipped with force sensors. Force distribution, total force, and displacement were recorded to a spread width of 10 cm in 18 corpses (11 males and 7 females; age, 62 ± 12 years). Both retractors were used in alternating sequence in 4 iterations in every corpse. Data were compared with respect to the different retractor blade shapes. RESULTS Maximum total forces for full retraction of both retractors resulted in 349.4 ± 77.9 N. Force distribution during the first retraction for the cranial/median/caudal part of the sternum was 101.5 ± 43.9/29.1 ± 33.9/63.0 ± 31.4 N for the SSR and 38.7 ± 41.3/80.9 ± 64.5/34.0 ± 25.8 N for the CSR, respectively. During the 4 spreading cycles, the average force decreased from 224.6 ± 61.3 N in the first to 110.8 ± 39.8 N in the fourth iteration. The mean total force for the first retraction revealed 226.4 ± 71.9 N for the CSR and 222.8 ± 52.9 N for the SSR. CONCLUSIONS The shape of sternal retractors considerably influences the force distribution on the sternal incision. In the SSR, forces on the cranial and caudal sternum are significantly higher than in the median section, whereas in the CSR, forces in the median section are highest.
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Affiliation(s)
- Philipp Aigner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria.
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Melly L, Gahl B, Meinke R, Rueter F, Matt P, Reuthebuch O, Eckstein FS, Grapow MTR. A new cable-tie-based sternal closure device: infectious considerations. Interact Cardiovasc Thorac Surg 2013; 17:219-23; discussion 223-4. [PMID: 23624983 DOI: 10.1093/icvts/ivt183] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine the difference in sternal infection and other infectious events between conventional wire and cable-tie-based closure techniques post-sternotomy in a collective of patients after cardiac surgery. METHODS The sternal ZipFix™ (ZF) system consists of a biocompatible poly-ether-ether-ketone (PEEK) cable-tie that surrounds the sternum through the intercostal space and provides a large implant-to-bone contact. Between 1 February 2011 and 31 January 2012, 680 cardiac operations were performed via sternotomy at our institution. After the exclusion of operations for active endocarditis and early mortality within 7 days, 95 patients were exclusively closed with ZF and could be compared with 498 who were closed with conventional wires (CWs) during the same period. A multivariable logistic regression analysis, including body mass index, renal impairment and emergency as suspected confounders and inverse propensity weights was performed on the infection rate. RESULTS Total infection rate was 6.1%, with a total of 36 diagnosed sternal infections (5 in ZF and 31 in CW). Comparing ZF with CW with regard to sternal infection, there is no statistically significant difference related to the device (odds ratio: 0.067, confidence interval: 0.04-9.16, P=0.72). The propensity modelling provided excellent overlap and the mean propensity was almost the same in both groups. Thus, we have observed no difference in receiving either ZF or CW. No sternal instability was observed with the ZF device, unlike 4/31 patients in the CW group. The overall operation time is reduced by 11 min in the ZF group with identical perfusion and clamping times. CONCLUSIONS Our study underlines a neutral effect of the sternal ZipFix™ system in patients regarding sternal infection. Postoperative complications are similar in both sternal closure methods. The cable-tie-based system is fast, easy to use, reliable and safe.
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Affiliation(s)
- Ludovic Melly
- Clinic for Cardiac Surgery, University Hospital Basel, Basel, Switzerland.
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Bejko J, Tarzia V, De Franceschi M, Bianco R, Castoro M, Bottio T, Gerosa G. Nitinol Flexigrip Sternal Closure System and Chest Wound Infections: Insight From a Comparative Analysis of Complications and Costs. Ann Thorac Surg 2012; 94:1848-53. [DOI: 10.1016/j.athoracsur.2012.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 08/04/2012] [Accepted: 08/10/2012] [Indexed: 11/25/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 401] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Chittithavorn V, Rergkliang C, Chetpaophan A, Simapattanapong T. Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection. Interact Cardiovasc Thorac Surg 2011; 12:982-6. [DOI: 10.1510/icvts.2011.265884] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Pre-educational intervention survey of healthcare practitioners’ compliance with infection prevention measures in cardiothoracic surgery: low compliance but internationally comparable surgical site infection rate. J Hosp Infect 2011; 77:348-51. [DOI: 10.1016/j.jhin.2010.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 12/30/2010] [Indexed: 11/19/2022]
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Bilal MS, Gürer O, Kırbaş A, Yıldız Y, Celebi A. Cardiac reoperation in a patient who previously underwent omentoplasty for postoperative mediastinitis: a case report. J Cardiothorac Surg 2011; 6:35. [PMID: 21435257 PMCID: PMC3079609 DOI: 10.1186/1749-8090-6-35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 03/24/2011] [Indexed: 11/10/2022] Open
Abstract
Sternal infection has become a rare but challenging problem with significant mortality and morbidity rates since the introduction of sternotomy. Reported rates of mediastinal and sternal infection range from 0.4% to 5%. The ideal reconstruction after sternal debridement is still controversial. Different methods, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition have been proposed. In this study, we present the cardiac reoperation of a 52 year old man with corrected transposition of great arteries (c-TGA) who had undergone a previous omentoplasty for postoperative mediastinitis.
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Affiliation(s)
- Mehmet S Bilal
- Department of Cardiovascular Surgery, Medicana Hospitals Camlica, Istanbul, Turkey.
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Sternal wound infection following open heart surgery: appraisal of incidence, risk factors, changing bacteriologic pattern and treatment outcome. Indian J Thorac Cardiovasc Surg 2011. [DOI: 10.1007/s12055-011-0081-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Mohd ARR, Ghani MK, Awang RR, Su Min JO, Dimon MZ. Dermacyn irrigation in reducing infection of a median sternotomy wound. Heart Surg Forum 2011; 13:E228-32. [PMID: 20719724 DOI: 10.1532/hsf98.20091162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Sternal wound infection is an infrequent yet potentially devastating complication following sternotomy. Among the standard practices used as preventive measures are the use of prophylactic antibiotics and povidone-iodine as an irrigation agent. A new antiseptic agent, Dermacyn super-oxidized water (Oculus Innovative Sciences), has recently been used as a wound-irrigation agent before the closure of sternotomy wounds. METHODS This prospective, randomized clinical trial was conducted to compare the effectiveness of Dermacyn and povidone-iodine in reducing sternotomy wound infection in patients undergoing coronary artery bypass graft surgery. Upon chest closure and after insertion of sternal wires, wounds were soaked for 15 minutes with either Dermacyn or povidone-iodine. Subcutaneous tissue and skin were then closed routinely. Patients were followed up, and any wound infection was analyzed. RESULTS Of the 178 patients, 88 patients were in the Dermacyn group, and 90 were in the povidone-iodine group. The mean (+/-SD) age of the patients was 61.1 +/- 7.6 years. The incidence of sternotomy wound infection was 19 cases (10.7%). Five (5.7%) of these cases were from the Dermacyn group, and 14 (15.6%) were from the povidone-iodine group (P = .033). No Dermacyn-related complication was identified. CONCLUSION We found Dermacyn to be safe and more effective as a wound-irrigation agent than povidone-iodine for preventing sternotomy wound infection.
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Transdermal Oxygen Does Not Improve Sternal Wound Oxygenation in Patients Recovering from Cardiac Surgery. Anesth Analg 2008; 106:1619-26. [DOI: 10.1213/ane.0b013e3181732e82] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Savage EB, Grab JD, O'Brien SM, Ali A, Okum EJ, Perez-Tamayo RA, Eiferman DS, Peterson ED, Edwards FH, Higgins RSD. Use of both internal thoracic arteries in diabetic patients increases deep sternal wound infection. Ann Thorac Surg 2007; 83:1002-6. [PMID: 17307448 DOI: 10.1016/j.athoracsur.2006.09.094] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND Use of both internal thoracic arteries has been limited in diabetic patients fearing an increased incidence of deep sternal wound infection. We analyzed this concern by querying The Society of Thoracic Surgeons Database. METHODS Diabetic patients who had isolated coronary artery bypass graft surgery during 2002 to 2004 were included if they had no prior bypass surgery, two or more distal bypasses, and a left internal thoracic artery bypass. Group B (both internal thoracic arteries) was compared with group L (left internal thoracic artery only). RESULTS The incidence of deep sternal wound infection for all patients undergoing isolated first-time bypass surgery was less than 1%. Of these, 120,793 patients met criteria for inclusion: group B, 1.4% (1732); and group L, 98.6% (119,061). Group B had a higher crude (unadjusted) deep sternal wound infection rate of 2.8% (49) versus 1.7% (1969; p = 0.0005) in group L, with an estimated odds ratio of 2.23 (95% confidence interval, 1.69 to 2.96). Group B had a similar crude mortality rate of 1.7% (30) versus 2.3% (2785; p = NS) in group L, with an estimated odds ratio of 1.110 (95% CI, 0.78 to 1.59; p = NS). Patients in group B were younger, mostly male, had a lower serum creatinine level, and were more often current smokers; less commonly, they were insulin dependent, diagnosed with pulmonary or vascular disease, or on dialysis. Other risk factors for deep sternal would infection included female gender, insulin dependence, peripheral vascular disease, recent infarction, body mass index exceeding 35 kg/m2, and use of blood products. CONCLUSIONS There is a significant increase in the incidence of deep sternal would infection in diabetic patients. This is further increased with the use of both internal thoracic arteries with no apparent short-term mortality difference.
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Affiliation(s)
- Edward B Savage
- Department of Surgery, St. John's Mercy Medical Center, St. Louis, Missouri, USA.
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Luciani N, Anselmi A, Gandolfo F, Gaudino M, Nasso G, Piscitelli M, Possati G. Polydioxanone Sternal Sutures for Prevention of Sternal Dehiscence. J Card Surg 2006; 21:580-4. [PMID: 17073957 DOI: 10.1111/j.1540-8191.2006.00302.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sternal dehiscence and wound instability are troublesome complications following median sternotomy. Classic sternal approximation with stainless steel wires may not be the ideal approach in patients predisposed to these complications. We tested the efficacy of polydioxanone (PDS) suture in sternal closure and in prevention of complications in comparison to steel wires in high-risk individuals. METHODS Three hundred sixty-six patients undergoing elective cardiac surgery with full median sternotomy and having body surface area (BSA) less than 1.5 m(2) were randomly assigned to receive PDS (n = 181) or stainless steel (SS, n = 185) sternal approximation. The study was focused on aseptic sternal complications, namely bone dehiscence and superficial wound instability. RESULTS Both bone dehiscence and superficial wound instability were less frequent in the PDS Group (4 and 3 cases in the SS Group, respectively, vs. no cases in the PDS Group). Cox proportional hazards regression model in the whole study population identified female sex, chronic renal insufficiency, diabetes, advanced age, lower sternal thickness, osteoporosis, corticosteroid therapy, and prolonged CPB or ventilation times as predisposing factors to any of the two studied sternal complications. DISCUSSION Data suggest that PDS suture can protect against development of aseptic sternal complications following median sternotomy in high-risk patients with little body mass. The adoption of PDS in other subsets of patients, i.e., obese individuals, is to be questioned.
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Affiliation(s)
- Nicola Luciani
- Department of Cardiovascular Medicine, Division of Cardiac Surgery, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
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Immer FF, Durrer M, Mühlemann KS, Erni D, Gahl B, Carrel TP. Deep sternal wound infection after cardiac surgery: modality of treatment and outcome. Ann Thorac Surg 2006; 80:957-61. [PMID: 16122463 DOI: 10.1016/j.athoracsur.2005.03.035] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Revised: 03/01/2005] [Accepted: 03/07/2005] [Indexed: 01/28/2023]
Abstract
BACKGROUND Deep sternal wound infection is a serious and expensive complication after cardiac surgical procedures. We tried to identify risk factors for failure of vacuum-assisted sternal closure and compare the outcome and long-term quality of life (QoL) with the results obtained after sternal resection and muscle flap. METHODS Between January 1998 and December 2003, 5,690 patients underwent cardiac surgical procedures at our institution. Fifty-five patients who had deep sternal wound infection were identified between January 1998 and December 2003. In-hospital data were assessed and the outcome was analyzed. QoL, using the Short Form 36 Health Survey Questionnaire (SF-36), was assessed and an additional questionnaire focused on specific problems. RESULTS Overall mortality was 5.4%. Patients with successful vacuum-assisted sternal closure were younger and had fewer cumulative risk factors (chronic obstructive pulmonary disease, bilateral internal mammary artery, obesity, diabetes), than patients in whom secondary closure failed. Quality of life was better among patients with secondary vacuum-assisted closure than among patients with musculocutaneous flap. Independently of the modality of treatment, pain was not a serious problem reported by the patients during the follow-up. CONCLUSIONS We conclude that preservation of the sternum should be the principal aim of surgical treatment in patients with deep sternal wound infection. Early diagnosis, aggressive surgical treatment by débridement, and the use of vacuum-assisted systems allows us to achieve a good long-term result with nearly normal QoL. Resection and musculocutaneous flap is a therapeutic option for high-risk patients, providing a safe, effective control of the infection, and it leads to acceptable results in terms of pain control and QoL.
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Affiliation(s)
- Franz F Immer
- Department of Cardiovascular Surgery, Inselspital, University Hospital, Berne, Switzerland.
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Tansley P, Kakar S, Withey S. A Novel Modification of Omental Transposition to Reduce the Risk of Gastrointestinal Herniation into the Chest. Plast Reconstr Surg 2006; 118:676-80. [PMID: 16932176 DOI: 10.1097/01.prs.0000233042.09732.7d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick Tansley
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London NW3 2QG, United Kingdom.
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Swenne CL, Lindholm C, Borowiec J, Carlsson M. Surgical-site infections within 60 days of coronary artery by-pass graft surgery. J Hosp Infect 2006; 57:14-24. [PMID: 15142711 DOI: 10.1016/j.jhin.2004.02.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Accepted: 01/30/2004] [Indexed: 11/29/2022]
Abstract
Surgical wound infections (SWIs) after coronary artery by-pass graft (CABG) within 30 and 60 days of operation were registered. Already known risk factors and possible risk factors for wound infection were studied. SWIs of sternal and/or leg wounds have been reported to occur in 2-20% of patients after CABG. Deep sternal infection, mediastinitis, occurs after 0.5-5% of CABG procedures. The duration and methods of follow-up, as well as definitions of SWI, vary in different studies. Previously known and possible new risk factors were registered for 374 patients. Patients were contacted by telephone 30 and 60 days after surgery and interviewed in accordance with a questionnaire about symptoms and signs of wound infections. Our definition of SWI was based on the Centers for Disease Control and Prevention (CDC) definition. SWIs were diagnosed in 114 of 374 (30.5%) of the patients. In total SWI were diagnosed in 120 surgical-site incisions. Almost all SWIs of the sternum (93.3%) were diagnosed within 30 days of surgery. Most of the SWIs of the leg (73%) were diagnosed within 30 days of surgery and 27% were diagnosed within 31 to 60 days of surgery. Being female was the most important risk factor for SWI of the leg. Low preoperative haemoglobin concentrations were the most important risk factor for superficial SWI on the sternum. Patients with mediastinitis had higher BMI and had more often received erythrocyte transfusions on postoperative day two or later than those without infections.
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Affiliation(s)
- C L Swenne
- FoUU-board, Karolinska University Hospital, H4:06, Stockholm, Sweden.
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Capuano F, Roscitano A, Simon C, Sclafani G, Benedetto U, Comito C, Tonelli E, Sinatra R. Intensive hyperglycemia control reduces postoperative infections after open heart surgery. Heart Int 2006; 2:49. [PMID: 21977251 PMCID: PMC3184653 DOI: 10.4081/hi.2006.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Diabetes mellitus increases the risk of infections in patients undergoing cardiac surgery. We hypothesized that intensive perioperative hyperglycemia control by intravenous insulin infusion reduces postoperative infections in all patients undergoing open heart surgical procedures. Methods: Sixty diabetics patients who underwent CABG operation (Group 1) were compared with fifty-five patients who underwent other cardiac surgery (Group 2) between January 2004 and March 2005. A continuous infusion of insulin was used in all these patients. Results: There were no 30-day mortalities in either group. There was no difference in the incidence of infections between the two groups: in Group 1, 3 (5%) patients were diagnosed to have postoperative infection (superficial sternal wound infections in 1 (1.66%) and lung infection in 2 (3.33%) patients); postoperative infection occurred in only 2 patients (3.63%) in Group 2, 1 superficial sternal wound infections (1.81%) and 1 lung infection (1.81%). Conclusions: Our analysis indicates that continuous intravenous insulin infusion improves outcome and reduces postoperative infections in patients undergoing CABG as well as those undergoing other cardiac surgery procedures.
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Affiliation(s)
- Fabio Capuano
- Department of Cardiac Surgery, St. Andrea Hospital, University of Rome "La Sapienza", Rome - Italy
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Aydin NB, Sener T, Kehlibar IK, Turkoglu T, Karpuzoglu OE, Ozkul V, Gercekoglu H. Sternal wound complications in bilateral internal thoracic artery grafting: a comparison of the off-pump technique and conventional cardiopulmonary bypass. Heart Surg Forum 2005; 8:E456-61; discussion E461. [PMID: 16286278 DOI: 10.1532/hsf98.20051150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Sternal wound complication is a major concern in bilateral internal thoracic artery grafting. The purpose of this study was to assess whether avoiding cardiopulmonary bypass has beneficial effects with fewer wound complications in patients receiving bilateral internal thoracic artery grafting. METHODS Retrospective review was performed using prospectively gathered data of 69 patients who had undergone elective coronary artery bypass grafting and received conventional pedicled bilateral internal thoracic artery grafting from December 2002 through April 2004 by the same surgical team. The patients were divided into 2 groups: those who underwent coronary artery bypass grafting without cardiopulmonary bypass (off-pump group, n = 41), and those who underwent coronary artery bypass grafting with cardiopulmonary bypass (CPB group, n = 28). Chart review and 3-month follow-up were obtained for all patients. These 2 groups were compared for sternal wound complications and preoperative, intraoperative, and postoperative variables. RESULTS Deep sternal wound infection (SWI) was seen in 1 patient (2.4%), superficial SWI in 2 patients (4.8%), and sternal dehiscence in 1 patient (2.4%) in the off-pump group. Deep SWI was seen in no patients, superficial SWI in 2 patients (7.1%) and sternal dehiscence in 2 patients (7.1%) in the CPB group. No statistically significant difference in the frequency of occurrence of sternal complications was detected between the 2 study groups. CONCLUSIONS The results suggest that the avoidance of CPB has no beneficial effect on the number of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. However, further prospective, randomized studies on large patient groups are required to assess this finding.
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Affiliation(s)
- Naz Bige Aydin
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Hospital, Istanbul, Turkey.
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Lepelletier D, Perron S, Bizouarn P, Caillon J, Drugeon H, Michaud JL, Duveau D. Surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors. Infect Control Hosp Epidemiol 2005; 26:466-72. [PMID: 15954485 DOI: 10.1086/502569] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify risk factors associated with surgical-site infection according to the depth of infection, the cardiac procedure, and the National Nosocomial Infections Surveillance System risk index. DESIGN Prospective survey conducted during a 12-month period. SETTING A 48-bed cardiac surgical department in a teaching hospital. PATIENTS Patients admitted for cardiac surgery between February 2002 and January 2003. RESULTS Surgical-site infections were diagnosed in 3% of the patients (38 of 1,268). Of the 38 surgical-site infections, 20 were superficial incisional infections and 18 were mediastinitis for incidence rates of 1.6% and 1.4%, respectively. Cultures were positive in 28 cases and the most commonly isolated pathogen was Staphylococcus. A National Nosocomial Infections Surveillance System risk index score of 2 or greater was associated with a risk of surgical-site infection (relative risk, 2.4; P < .004). Heart transplantation, mechanical circulatory assistance, coronary artery bypass graft with the use of internal mammary artery, and reoperation for cardiac tamponade or pericard effusion were independent risk factors associated with surgical-site infection. CONCLUSIONS Data surveillance using incidence rates stratified by cardiac procedure and type of infection is relevant to improving infection control efforts. Risk factors in patients who developed superficial infection were different from those in patients who developed mediastinitis. Coronary artery bypass graft using internal mammary artery was associated with a high risk of surgical-site infection, and independent factors such as reoperation for cardiac tamponade or pericard effusion increased the risk of infection.
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Affiliation(s)
- Didier Lepelletier
- Bacteriology and Infection Control Laboratory and the Department of Cardiac Surgery, Laennec Hospital, Nantes, France.
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Bruhin R, Stock UA, Drücker JP, Azhari T, Wippermann J, Albes JM, Hintze D, Eckardt S, Könke C, Wahlers T. Numerical Simulation Techniques to Study the Structural Response of the Human Chest Following Median Sternotomy. Ann Thorac Surg 2005; 80:623-30. [PMID: 16039217 DOI: 10.1016/j.athoracsur.2005.03.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 02/17/2005] [Accepted: 03/03/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal closure technique of median sternotomy remains controversial. The objective of this study was to analyze the structural response of the separated sternum using computer-based numerical discretization techniques, such as finite element methods. METHODS Thoracic computer tomographic scans (2.5-mm slices) were segmented, analyzed by image processing techniques, and transferred into a three-dimensional finite element model. In a first approach a linear elastic material model was used; neglecting nonlinear and damage effects of the bones. The influence of muscles and tendons was disregarded. Nonlinear contact conditions were applied between the two sternal parts and between fixation wires and sternum. The structural response of this model was investigated under normal breathing and asymmetric leaning on one side of the chest. Displacement and stress response of the segmented sternum were compared regarding two different closure techniques (single loop, figure-of-eight). RESULTS The obtained results revealed that for the normal breathing load case the single loop technique is capable of clamping the sternum sufficiently, assuming that the wires are prestressed. For asymmetric loading conditions, such as leaning on one side of the chest, the figure-of-eight loop can substantially reduce the relative longitudinal displacement between the two parts compared with the single loop. CONCLUSIONS The application of numerical simulation techniques using complex computer models enabled the determination of structural behavior of the chest regarding the influence of different closure techniques. They allowed easy and fast modifications and therefore, in contrast to a real physical model, in-depth parameter studies.
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Affiliation(s)
- Raimund Bruhin
- Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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Dogan OF, Oznur A, Demircin M. A New Technical Approach for Sternal Closure with Suture Anchors (Dogan Technique). Heart Surg Forum 2004; 7:E328-32. [PMID: 15454387 DOI: 10.1532/hsf98.20041038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Various methods for sternal approximation have been described previously. Some patients undergoing these procedures are at risk for sternal dehiscence and mediastinitis. We used a different method, with a suture anchor system, for median sternotomy closure as an alternate technique in patients with a high risk of postoperative sternal dehiscence and sternal nonunion. MATERIAL AND METHOD Suture anchor systems have been developed principally for the fixation of tendons or ligaments to the bone. We first used the suture anchor system for median sternotomy closure, although it has been frequently used in various orthopedic surgical procedures. In this report, we describe the use, after fresh cadaveric tests, of an alternative technique in a patient undergoing coronary artery bypass grafting. RESULTS There were no complications due to the suture anchor device, and successful application was performed for sternotomy fixation after surgical procedure in a patient. The standard techniques have several disadvantages, such as osteomyelitis, chondritis, cutting into the sternum and sternal dehiscence, prolonged hospitalization, and increased mortality and morbidity due to the listed complications, but these devices may protect the wire from cutting into the sternal bone. CONCLUSION We propose suture anchors for reapproximation of the sternum to decrease the complications related to surgical steel wires. We therefore consider this technique to be easy, safe, and effective in patients with diabetes mellitus or severe osteoporosis considered to have risk for sternal dehiscence postoperatively. Another advantage of this suture system is that the titanium wire makes it more magnetic resonance compatible than systems using surgical steel wire.
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Affiliation(s)
- Omer Faruk Dogan
- Hacettepe University Faculty of Medicine, Department of Cardiovascular Surgery, Ankara, Turkey.
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Flückiger U, Zimmerli W. [Diagnosis and follow-up management of postoperative bacterial osteitis]. DER ORTHOPADE 2004; 33:416-23. [PMID: 15024462 DOI: 10.1007/s00132-003-0606-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Osteomyelitis is a term used to describe bone infection. As a complication, it can occur after open bone fracture and is associated with the implantation of foreign material. Acute disease after surgery starts after about 7 days to 4 weeks, and is characterized by a suppurative infection. Chronic infection sometimes manifests even years after surgery with a purulent sinus tract. Diagnosis is based on clinical signs, microbiological culture, histological evidence of the presence of granulocytes, and on radiological signs of osteomyelitis. However, it is sometimes difficult to distinguish between merely soft tissue involvement and osteomyelitis, especially in the presence of implanted material. Management includes a thoroughly surgical débridement and antibiotic treatment. Though frequently used, bacterial cultures of swabs of superficial wounds or fistulas are often misleading, whereas needle biopsy or surgical sampling with at least three tissue samples provides more reliable information. Because of the prolonged antibiotic treatment, it is mandatory for a successful outcome to culture the microorganism in order to determine antibiotic susceptibility. In addition to conventional radiological approaches, magnetic resonance imaging has become useful for the diagnosis of osteomyelitis. Despite significant progress in antibiotic therapy and orthopedic surgery, osteomyelitis remains difficult to treat and often relapses, even after years.
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Affiliation(s)
- U Flückiger
- Klinik für Infektiologie, Kantonsspital, Universitätskliniken Basel, Switzerland.
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Sarria JC, Perez-Verdia A, Kimbrough RC, Vidal AM. Deep sternal wound infection caused by group g streptococcus after open-heart surgery. Am J Med Sci 2004; 327:253-4. [PMID: 15166743 DOI: 10.1097/00000441-200405000-00021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report the first case of deep sternal wound infection caused by group G Streptococcus after open-heart surgery. The patient's clinical presentation was nonspecific and his diagnosis was delayed. Surgical debridement and a 4-week course of intravenous antibiotics consisting of sequential penicillin plus gentamicin/ceftriaxone led to recovery. Group G Streptococcus should be suspected as an important postoperative pathogen.
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Affiliation(s)
- Juan C Sarria
- Division of Infectious Diseases, Texas Tech University Health Sciences Center, Lubbock 79430, USA.
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Sung K, Jun TG, Park PW, Park KH, Lee YT, Yang JH. Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps. Ann Thorac Surg 2004; 77:1371-5. [PMID: 15063269 DOI: 10.1016/j.athoracsur.2003.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2003] [Indexed: 11/18/2022]
Abstract
BACKGROUND Advanced pectoralis major muscle flaps can be used to treat deep sternal wound infections in children; however, the long-term outcomes have not been widely reported. METHODS We retrospectively reviewed 11 patients (median age, 3.8 months), who had developed deep sternal wound infections following median sternotomy, among 1380 consecutive pediatric cardiac procedures from January 1995 to July 2001. RESULTS Advanced pectoralis major muscle flaps were used in 10 patients bilaterally and in 1 patient unilaterally. All survived and were discharged without evidence of infection. During a mean +/- standard deviation follow-up of 42.1 +/- 20.9 months, there was no evidence of recurrent or chronic infection. All patients demonstrated normal development with no limitations to their upper trunk or limb movements. All of the 6 patients who had undergone a palliative operation initially had additional operations without difficulty through the existing sternotomy incision. CONCLUSIONS This technique proved to be easy and promoted wound healing that covered all of the sternal wound defects without tension and without requiring additional flaps. It produced minimal growth and developmental problems, and it might facilitate additional operations.
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Affiliation(s)
- Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Seoul Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Sénéchal M, LePrince P, Tezenas du Montcel S, Bonnet N, Dubois M, El-Serafi M, Ghossoub JJ, Pavie A, Gandjbakhch I, Dorent R. Bacterial mediastinitis after heart transplantation: clinical presentation, risk factors and treatment. J Heart Lung Transplant 2004; 23:165-70. [PMID: 14761763 DOI: 10.1016/s1053-2498(03)00104-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2002] [Revised: 12/20/2002] [Accepted: 01/13/2003] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The incidence of mediastinitis after heart transplantation has been reported to be between 2.5% and 7.5%. Most previous reports from the transplant literature have assessed patients who had not received induction therapy. METHODS From December 1996 to January 2002, a total of 230 heart transplants were performed using induction therapy with rabbit anti-thymocyte globulin at La Pitié Salpêtrière Hospital (Paris, France). Mediastinitis developed in 15 patients (6.5%). A case-control study was performed to characterize the clinical presentation, microbiology, risk factors and therapy of mediastinitis after heart transplantation. RESULTS Only 4 patients (26%) had a temperature of >38 degrees C and 6 patients (40%) had a white blood cell count of >10,000 cells/mm(3). Septicemia (46%) and positive temporary epicardial pacing wires culture (60%) were frequently observed. Staphylococcus aureus (5 of 15), Staphylococcus epidermidis (5 of 15) and gram-negative bacteria (5 of 15) were the causative organisms cultured intra-operatively. Mean duration of mechanical ventilation (2.4 vs 1.6 days; p < 0.03) and use of ventricular assistance (20% vs 0%; p < 0.04) were different between cases and controls. The mortality rate at hospital discharge was 6.7% (1 of 15). CONCLUSIONS In the context of immunosuppression after heart transplantation, a high degree of suspicion is necessary to make the diagnosis of mediastinitis. Positive blood and temporary epicardial pacing wires cultures can be helpful in suggesting the presence of mediastinitis. Using vancomycin and an aminoglycoside as prophylaxis has to be considered because of the high prevalence of methilcilin-resistant S epidermidis and gram-negative bacteria. Conservative therapy (sternal debridement without muscle flap closure, and closed-chest drainage) showed excellent results in this series.
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Affiliation(s)
- Mario Sénéchal
- Service de Chirurgie Cardio-Vasculaire et Thoracique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Thakar CV, Yared JP, Worley S, Cotman K, Paganini EP. Renal dysfunction and serious infections after open-heart surgery. Kidney Int 2003; 64:239-46. [PMID: 12787415 DOI: 10.1046/j.1523-1755.2003.00040.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Infections and sepsis are important determinants of mortality in patients with renal dysfunction. We studied the influence of preoperative renal function or postoperative acute renal failure (ARF) on the frequency of infections after open-heart surgery. METHODS This was a retrospective analysis of 24,660 patients undergoing open-heart surgery from 1993 to 2000. Primary outcome was occurrence of serious infections after open-heart surgery; secondary outcome was hospital mortality. RESULTS Overall incidence of infections after open-heart surgery was 3.3%. The infection rate was higher in patients with lower preoperative creatinine clearance, ranging between 2.2% and 10.0%. Regarding postoperative ARF, the frequency of infections was 58.5% in those patients requiring dialysis vs. 23.7% in those with ARF not requiring dialysis (P < 0.001); within each subgroup, however, the infection rates were similar regardless of the baseline renal function. In patients who did not develop ARF by either of our definitions, the infection rate was 1.6%. By multivariate analysis, preoperative renal function was an independent risk factor associated with infections [odds ratio (OR) for preoperative creatinine>1.2 mg/dL, 1.3; CI, 1.1 to 1.6]. The relationship between preoperative renal function and infection prevailed even after excluding the patients with postoperative ARF. The overall morality was 2.2%; the mortality in patients with serious infection was 31.7%. CONCLUSION Both preoperative renal dysfunction and postoperative ARF influence the frequency of serious infections after open-heart surgery. The infection rate was higher in patients with postoperative ARF regardless of the baseline renal function. However, preoperative renal dysfunction portended higher risk of infection, independent of the influence of postoperative ARF.
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Affiliation(s)
- Charuhas V Thakar
- Department of Nephrology and Hypertension, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Risnes I, Abdelnoor M, Lundblad R, Baksaas ST, Svennevig JL. Leg wound closure after saphenous vein harvesting in patients undergoing coronary artery bypass grafting: a prospective randomized study comparing intracutaneous, transcutaneous and zipper techniques. SCAND CARDIOVASC J 2002; 36:378-82. [PMID: 12626207 DOI: 10.1080/140174302762659120] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Two prospective randomized studies were undertaken to compare different suture closure techniques with respect to postoperative wound infection rates and cosmetic results after saphenous vein harvesting in patients undergoing coronary artery bypass surgery. DESIGN A total of 166 patients were included in the first study, in which 85 had their leg wounds closed with transcutaneous and 81 with intracutaneous suture. In the second study, 168 patients were selected to a non-invasive surgical zipper (n = 78) or intracutaneous suture (n = 90). RESULTS In the first study the overall infection rate was 20.5%, 17.6% in the transcutaneous group compared with 23.5% in the intracutaneous group (p = 0.35). In the second study the infection rate was 19.3%, 15.3% in the zipper group vs 23.3% in the intracutaneous group (p = 0.20). On a cosmetic scale from 1 to 10, an average score of 8.0 was obtained in the percutaneous (p.c.) group vs 8.3 in the intracutaneous (i.c.) group (p = 0.35), and 9.0 in the zipper group vs 8.4 in the i.c. group (p = 0.003). CONCLUSION The incidence of leg wound infection after saphenous vein harvesting in coronary artery bypass graft surgery is high. The zipper closing method may give a lower infection rate and a better cosmetic result compared with the intracutaneous suture.
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Affiliation(s)
- Ivar Risnes
- Department of Thoracic and Cardiovascular Surgery, Rikshospitalet, NO-0027 Oslo, Norway.
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Olsen MA, Lock-Buckley P, Hopkins D, Polish LB, Sundt TM, Fraser VJ. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg 2002; 124:136-45. [PMID: 12091819 DOI: 10.1067/mtc.2002.122306] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine risk factors for deep and superficial chest wound infections after coronary artery bypass graft surgery to develop predictive models. METHODS We retrospectively analyzed data collected on 1980 consecutive patients undergoing coronary artery bypass surgery at our institution between January 1, 1996, and June 30, 1999, by using the Society of Thoracic Surgery database. Independent risk factors for surgical-site infection were identified with multivariate logistic regression. RESULTS There were 37 (1.9%) deep chest and 46 (2.3%) superficial chest surgical-site infections. Obese diabetic patients had a 7.7-fold increased risk of deep chest infections after controlling for intra-aortic balloon pump use (odds ratio, 3.1) and postoperative transfusion (odds ratio, 2.3). Independent risk factors for superficial surgical-site infections included obesity (odds ratio, 3.1), diabetes in persons 65 years of age or older (odds ratio, 2.7), and current smoking (odds ratio, 2.5). Use of antiplatelet drugs was associated with a lower risk of superficial infections (odds ratio, 0.4). Predicted operative mortality as a marker of severity of illness was not clearly predictive of deep or superficial surgical-site infection. Mortality in the year after the operation was increased in patients with deep chest infections compared with that seen in uninfected control subjects (8/37 [21.6%] vs 114/1612 [7.1%], P =.004) but not in patients with superficial chest infections (7/47 [15.2%] vs 114/1612 [7.1%], P =.075). CONCLUSIONS Risk factors for deep and superficial chest surgical-site infections after coronary artery bypass surgery differ, suggesting different mechanisms of pathogenesis. Appropriate risk stratification models specific to these important outcomes must be developed.
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Affiliation(s)
- Margaret A Olsen
- Division of Infectious Diseases and Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
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Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis. J Thorac Cardiovasc Surg 2002; 123:1185-90. [PMID: 12063467 DOI: 10.1067/mtc.2002.121304] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.
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Affiliation(s)
- R Wettstein
- Division of Plastic Surgery, Inselspital University Hospital, Berne, Switzerland
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47
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Chelemer SB, Prato BS, Cox PM, O'Connor GT, Morton JR. Association of bacterial infection and red blood cell transfusion after coronary artery bypass surgery. Ann Thorac Surg 2002; 73:138-42. [PMID: 11834000 DOI: 10.1016/s0003-4975(01)03308-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous studies have shown an association between red blood cell transfusions (RBC) and bacterial infections following coronary artery bypass graft (CABG) surgery. We sought to assess whether there is an independent effect of RBC on the incidence of bacterial infections. METHODS This was a prospective cohort study of 533 CABG patients over a 7-month period. Subjects were followed from time of CABG until 30 days postoperatively. Data were collected on patient and treatment characteristics, surgical management, and transfusion incidence. RESULTS Seventy-five (14.1%) of 533 patients developed a bacterial infection. After controlling for patient and disease characteristics, invasive treatments, surgical time, and the transfusion of other substances, the adjusted rates of bacterial infection were 4.8% for no RBC transfusion, 15.2% with one to two units, 22.1% with three to five units, and 29.0% with greater than or equal to six units, (p(trend) < 0.001). Diabetes was the only patient or disease factor significantly associated with bacterial infection (p < 0.001). CONCLUSIONS RBC transfusions were independently associated with a higher incidence of post-CABG bacterial infections. The risk of infection increased in proportion to the number of units of RBC transfused.
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Affiliation(s)
- Scott B Chelemer
- Department of Medicine, Maine Medical Center, Portland 04102, USA
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48
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Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. Ann Thorac Surg 2001; 72:1587-91. [PMID: 11722049 DOI: 10.1016/s0003-4975(01)03102-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracutaneous suture technique has been our standard method for closing sternal wounds in cardiac surgery, mainly for cosmetic reasons. However, an increased rate of postoperative infections has been reported in cosmetic surgery with this method compared with the percutanous or transcutaneous closure technique. A comparison of these two techniques in cardiac surgery is presented. METHODS In a randomized study, 300 patients were selected to intracutaneous suture (n = 150) or percutanous suture (n = 150). The endpoints were superficial and deep sternal wound infections within 6 weeks postoperatively. RESULTS The total infection rate was lower in the percutanous group compared with the intracutaneous group (3% versus 8%) (p = 0.007). The superficial infection rate was lower in the percutaneous group (2.3% versus 6.7%) (p = 0.01), whereas there was no statistically significant difference in the deep infection rate between the groups. CONCLUSIONS The percutaneous suture technique reduces the incidence of superficial wound infections, but not the deep infection rate in open heart surgery. There was no difference in the cosmetic results on a visual scale, assessed by the patients.
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Affiliation(s)
- I Risnes
- Department of Thoracic and Cardiovascular Surgery, Rikshospitalet, Oslo, Norway.
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De Feo M, Gregorio R, Della Corte A, Marra C, Amarelli C, Renzulli A, Utili R, Cotrufo M. Deep sternal wound infection: the role of early debridement surgery. Eur J Cardiothorac Surg 2001; 19:811-6. [PMID: 11404135 DOI: 10.1016/s1010-7940(01)00676-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This retrospective chart review study aimed to evaluate whether a more aggressive staged approach can reduce morbidity and mortality following post-cardiotomy deep sternal wound infection. METHODS Between 1979 and 2000, 14620 patients underwent open heart surgery: mediastinitis developed in 124 patients (0.85%). Patients were divided in two groups: in 62 patients (Group A) (1979-1994) an initial attempt of conservative antibiotic therapy was the rule followed by surgical approach in case of failure; in 62 patients (Group B) (1995-2000) the treatment was staged in three phases: (1) wound debridement, removal of wires and sutures, closed irrigation for 10 days; (2) in case of failure open dressing with sugar and hyperbaric therapy (11 patients, 17%); (3) delayed healing and negative wound cultures mandated plastic reconstruction (three patients, 4%). Categorical values were compared using the Chi-square test, continuous data were compared by unpaired t-test. RESULTS Incidence of mediastinitis was higher in Group B (62 out of 5535; 1.3%) than in Group A (62 out of 9085; 0.7%) (P=0.007). Mean interval between diagnosis and treatment was shorter in Group B (18+/-6 days) than in group A (38+/-7 days) (P=0.001). Hospital mortality was higher in Group A (19/62; 31%) than in Group B (1 out of 62; 1.6%) (P<0.001). Hospital stay was shorter in Group B (30.5+/-3 days) than in group A (44+/-9 days) (P=0.001). In Group B complete healing was observed in all the 61 survivors: 47 cases (76%) after Stage 1; 11 (18%) after Stage 2; three (4.8%) after Stage 3. CONCLUSIONS Although partially biased by the fact that the two compared groups draw back to different decades, this study showed that an aggressive therapeutic protocol can significantly reduce morbidity and mortality of deep sternal wound infection.
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Affiliation(s)
- M De Feo
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples, Italy
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De Feo M, Renzulli A, Ismeno G, Gregorio R, Della Corte A, Utili R, Cotrufo M. Variables predicting adverse outcome in patients with deep sternal wound infection. Ann Thorac Surg 2001; 71:324-31. [PMID: 11216770 DOI: 10.1016/s0003-4975(00)02137-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Mortality after deep sternal wound infection (DSWI) ranges between 5% and 47%. Variables predicting hospital mortality and prolonged hospital stay are still to be assessed. METHODS Among 13,420 patients who underwent cardiac surgery in our institution between 1979 and 1999, DSWI developed in 112 cases (0.8%). Multiple variables were recorded prospectively and analyzed retrospectively as predictors of hospital death and prolonged (>30 days) hospital stay. The analyzed variables were divided into three groups: (1) related to the patient, including demographic variables and preoperative conditions; (2) related to cardiac operation; and (3) related to infection. Predictive variables were assessed by univariate and multivariate logistic regression analysis. RESULTS Hospital mortality was 16.9%. The hospital stay of the 93 discharged patients ranged between 16 and 180 days (mean 31.3 +/- 15.2). Length of cardiac operation, length of stay in intensive care unit, interval between symptoms of DSWI and wound debridement were found to be the most significant predictors of bad outcome following DSWI. CONCLUSIONS In our study demographic variables and preoperative conditions did not affect the prognosis of DSWI. Lower mortality rate and shorter hospital stay could be achieved with earlier and aggressive treatment of DSWI.
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Affiliation(s)
- M De Feo
- Institute of Cardiac Surgery, V. Monaldi Hospital, and Infectious Diseases, Second University of Naples, Italy
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