[Postoperative sternomediastinitis]

[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]

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.

[A new paradigm for the treatment of sternomediastinitis]

OBJECTIVE

To analyze the results of simultaneous surgical treatment of sternomediastinitis compared to stage-by-stage approach.

MATERIAL AND METHODS

The study included 27 patients between October 2022 and March 2023. All patients underwent heart surgery through median sternotomy. There were 11 (40.7%) women and 16 (59.3%) men. Mean age of patients was 68.4±9.8 years. All patients were divided into 2 groups: 12 patients underwent partial necrectomy and vacuum wound therapy (or long-term dressings) before surgery (group 1), 15 patients underwent surgery without prior conservative treatment (group 2).

RESULTS

The most common causative agent of infection was staphylococcus (48.1%). In all patients, we found histological signs of osteomyelitis. Preoperative clinical status was similar in both groups. There were differences in the following indicators: C-reactive protein upon admission - 74.9±18.6 versus 94.8±23.8 mg/l, procalcitonin - 0.13 [0.02; 1.43] versus 0.21 [0.02; 0.94] ng/ml. Postoperative outcomes were similar in both groups. Mortality was 8.3% (n=1) and 13.3% (n=2), respectively.

CONCLUSION

Simultaneous combined surgical treatment (sequestrectomy + muscle flap grafting) demonstrates optimal results in the treatment of sternomediastinitis.

[Local infectious complications in cardiac surgery: etiology and the role of antimicrobial prophylaxis]

OBJECTIVE

To investigate the relationship between antimicrobial prophylaxis protocol, prevalence and etiology of local infectious complications after open cardiac surgery.

MATERIAL AND METHODS

A retrospective cohort observational study was performed between 2010 and 2019 at the Ural Institute of Cardiology. Antimicrobial prophylaxis was performed using the main (cefuroxime 1.5 g IV every 6 hours) and alternative protocols (vancomycin 15 mg/kg IV every 12 hours).

RESULTS

The prevalence of local infectious complications throughout the entire follow-up period was 4.5±0.3% [95% CI 4.45-4.54]. There were 42 cases of deep infection (0.9±0.13%). Coagulase-negative staphylococci prevailed (15.9±2.5% of cases, 35 cultures). Resistant flora included coagulase-negative methicillin-resistant staphylococci (13 cultures, 37.1±8.2%) and representatives of Enterobacteriaceae family, producers of extended-spectrum beta-lactamase (8 cultures, 50.0±18.2%). Antimicrobial prophylaxis with vancomycin increases the risk of local infectious complications (OR 1.75, 95% CI 1.20, 2.55, p=0.001). Both protocols of antimicrobial prophylaxis demonstrated comparable efficacy against gram-positive and gram-negative microorganisms.

CONCLUSION

Coagulase-negative staphylococci are the most common cause of local infectious complications in cardiac surgery. Modern antimicrobial prophylaxis regimens are relevant despite resistant flora.