Deep Sternal Wound Infection Research Articles

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

THERMOACTIVE NITINOL CLIPS AS PRIMARY AND SECONDARY STERNAL CLOSURE AFTER CARDIAC SURGERY - FIRST EXPERIENCE IN SLOVENIA.

SUMMARYAlthough there has been a trend towards minimally invasive and sternum-sparing procedures, median sternotomy is still a standard surgical approach in cardiac surgery. Many techniques and innovations for closure of sternal osteotomy have been developed with contradictory results. In this report, we present our first experience with the nitinol-made sternal closure system in the primary, as well as secondary closure of sternal osteotomy. A small series of 20 patients had their sternotomy closed with Flexigrip clips. In one case, the Flexigrip clips were used in secondary wound closure in a patient with deep sternal wound infection after full sternotomy and coronary bypass surgery. After 6-month follow-up, all patients were doing well with their sternums clinically stable and the sternotomy wounds completely healed. In conclusion, Flexigrip clips offered a stable alternative to steel wires in primary, as well as secondary sternal closure. Moreover, in secondary sternal closure, the thermoactive clips offered safety advantages over the standard wire cerclage technique because the need for dissection of the substernal adhesions could be avoided.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics.

IntroductionUse of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up.MethodsThis is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample.ResultsPreoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40).ConclusionWe did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

P61 An Unusual Case of Intermittent Cardiac Tamponade

A 64-year-old man presented to his GP complaining of intermittent shortness of breath on exertion, particularly when constipated. His background included coronary artery bypass surgery 20 years ago using bilateral internal thoracic arteries and the left radial artery; this was complicated by deep sternal wound infection that required sternal debridement and bilateral pectoral flaps advancement. A recurrent infection some time later was treated with a second debridement and partial sternectomy followed by pedicled omental flap reconstruction.

M10 Disparities in Sternal Wound Infection After Cardiac Surgery Between Indigenous and non-Indigenous Australians

A detailed investigation of sternal wound infection in Australian Indigenous and non-Indigenous patients undergoing cardiac surgery has not been previously reported. Therefore, we aimed to evaluate all sternal wound infections and deep sternal wound infections (DSWI) for these two groups.

M30 Novel Sternal Closure Technique Using the Claw Sternal Fixation System

Median sternotomy is the most common technique used to gain access to the heart in cardiac surgery. Despite evidence suggesting superiority of rigid fixation systems, steel wire cerclage remains the most widespread method for sternal closure. It has been widely reported in literature that poor sternal closure contributes to complications including deep sternal wound infection (DSWI), sternal dehiscence and mediastinitis. The ideal sternal closure technique should immobilise the two cut edges, resist the biomechanical forces placed on the sternum, have low complications, be easy to use, easy to remove on re-entry, minimise pain, and be cost effective.

Modified Ravitch Procedure for Pectus Excavatum Combined With Complex Cardiac Surgery

Pectus excavatum is common in patients with connective tissue disorders or congenital heart disease undergoing cardiac surgery, and is occasionally severe enough to warrant repair. The optimal surgical strategy is currently debated. We report our experience with simultaneous repair. From January 2012 to January 2020, 11 patients (median age of 35 ± 18 years, range 12-74) underwent a modified Ravitch procedure for severe pectus excavatum performed by a single thoracic surgeon at the time of simultaneous complex cardiac surgery. Eight patients (73%) had a confirmed connective tissue disorder and 2 patients (18%) had recurrent pectus excavatum following a failed Nuss procedure in adolescence. The mean Haller index was 7.3 ± 3.2 (range 3.8-13). The most common concomitant cardiac procedures were valve-preserving aortic root replacement (n=7, 64%) and mitral valve repair (n = 4, 36%). Patients are presented as a case series with descriptive analysis. The median total operative and cardiopulmonary bypass times were 400 minutes (±109 minutes) and 168 minutes (± 43 minutes), respectively. No deaths occurred in-hospital or during follow-up. There were no reoperations for bleeding, tamponade or other indications. No deep or superficial sternal wound infections occurred. Postoperative analgesia regimens were multimodal to facilitate early mobilization and pulmonary hygiene. None of the patients required prolonged ventilation or reintubation for respiratory failure. The mean stay in the intensive care unit was 82 hours (±56 hours) and the mean hospital stay was 9.1 days (2.4 days). Concurrent pectus excavatum repair at the time of cardiac surgery using a modified Ravitch technique can be safely performed by a multi-disciplinary team and should be considered for patients with multiple indications for operation.

Upper mini-sternotomy versus right mini-thoracotomy approach in mitral valve surgery

Background: Full median sternotomy has been a standard surgical approach for heart surgery for more than 50 years. Several advantages increasing the use of less invasive approaches to the mitral valve surgery including, cosmetic, blood product use, respiratory, and pain advantages over conventional surgery. Parasternal incision, right mini-thoracotomy and partial sternotomy are described approaches for less invasive cardiac surgery. Objective: Comparing the less invasive approaches via upper partial sternotomy vs right mini-thoracotomy in mitral valve surgery. Methods: Sixty patients, underwent mitral valve surgery in NHI, were enrolled in this study and divided into two equal groups, and randomly assigned into two equal groups: group upper mini-sternotomy (UMS group, n = 30) or group RMT group (n = 30).The preoperative characteristics, operative variables, mortality, and morbidity were analyzed prospectively. Results: No difference were found between the two groups as regards the mortality. However, in Group UMS, blood loss was significantly higher, also cross clamp time and total bypass time were significantly longer. RMT group showed less time on mechanical ventilation, ICU stay and total hospital stay. In Group UMS, two patients (7%) developed deep sternal wound infection, and one patient (3%) suffered unstable sternum and one patient (3%) required permanent pacemaker. Conclusion: Both approaches upper partial sternotomy and right mini thoracotomy are considered a safe alternative for mitral valve replacement and can provide adequate exposure for mitral valve. In Upper partial sternotomy, conventional cardiopulmonary bypass, no specific instruments or endoscope were needed. In right mini thoracotomy, a longer learning curve and special instruments were required, however, it carried better outcome considering patient satisfaction for pain and cosmetic outcome the hospital stay and short return to activity.

Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection

Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).

R23 Twenty-Year Survival After RAY is the Same as BIMAY Operations for Coronary Bypass Surgery

Composite grafting with two arterial conduits efficiently achieves total arterial revascularisation of triple vessel disease. The left internal mammary artery may be used with the second conduit being a free right mammary (BIMAY) or a radial artery (RAY). There have been no direct comparisons of survival between BIMAY and RAY beyond 7 years. Use of both internal mammary arteries may increase the risk of deep sternal wound infection, whereas use of the radial artery may potentially reduce this risk.

Does routine topical antimicrobial administration prevent sternal wound infection after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does routine topical antimicrobial administration prevent sternal wound infection (SWI) after cardiac surgery? Altogether >238 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several different antimicrobial agents, dosages and application protocols were found in the literature. Regarding topical vancomycin use, a meta-analysis by Kowalewski et al. demonstrated a 76% risk reduction in any SWI. Collagen-gentamicin sponge application was associated with a 38% risk reduction in SWI in another meta-analysis by Kowalewski et al., which included 4 randomized control trials and >23 000 patients. Lower evidence observational studies found benefit in the use of different regimes, including: combination of vancomycin paste and subcutaneous gentamycin; combined cefazoline and gentamicin spray; isolated cefazolin; bacitracin ointment; and rifampicin irrigation. We conclude that, in light of the body of evidence available, topical antibiotic application prevents SWI, including both superficial and deep SWI. The strongest evidence, derived from 2 meta-analyses, is related to the use of gentamicin-collagen sponges and topical vancomycin. Heterogeneity throughout studies regarding antibiotic agents, dosages, application protocols and SWI definition makes providing general recommendations challenging.

Vacuum assistance therapy as compared to early reconstructive treatment in deep sternal wound infection.

Background and Aims:Deep sternal wound infection is a major concern after cardiac surgery. This study describes the incidence of postoperative deep sternal wound infections after cardiac surgery and compares two available treatment modalities.Materials and Methods:In Tampere University Hospital, 7973 open heart operations were performed between 2007 and 2016. Patients treated for a postoperative deep sternal wound infection were categorized in two groups based on treatment: revision surgery with early reconstruction (revision group; 74 patients) or vacuum-assisted closure treatment (VAC group; 55 patients). The end points in comparisons were overall mortality and hospitalization time.Results:A total of 129 patients (1.6%) developed a postoperative deep sternal wound infection. The 30-day mortality rates were 8.1% and 3.6%, the 90-day mortality rates were 15.5% and 18.2%, and the 1-year mortality rates were 17.6% and 23.6% for the revision and VAC group, respectively. There was no statistically significant difference in mortality rates. The hospital stay was 18 days in the revision group and 38 days in the VAC group (p < 0.001). The secondary intensive care unit stay was longer in the VAC group (median 1 vs 4, p = 0.011). The most common pathogens isolated in the first reoperation were coagulase-negative staphylococci (33.8% and 41.8%, respectively; p = 0.366), and positive candida findings were more common in the VAC group (4.1% vs 37.0 %, p < 0.001).Conclusion:Vacuum-assisted closure treatment induces an inferior outcome in terms of fungal infections, treatment times, and the number of reoperations.

Comparative Study Between the effect of Skeletonized and Pedicled Internal Thoracic Artery on sternum healing in Patient Undergoing CABG

Background: Myocardial revascularization is performed preferentially with internal thoracic artery grafts. This study aimed to investigate sternal healing over time and the incidence of poor sternal healing and wound infection in patients undergoing coronary artery bypass graft (CABG) surgery using skeletonized internal thoracic artery. Objectives: (1) comparison of two surgical take-down techniques (skeletonizing vs. standard pedicle harvestation); (2) assessment of sternal healing and wound infection. Method: This study enrolled 50 patients (divided in two groups) who underwent isolated CABG using skeletonized internal thoracic artery (25 patients) and pedicled internal thoracic artery (25 patients) from December 2017 to August 2019. Postoperative assessment was performed on all patients for three months after surgery. In all patients, chest X-ray study was performed after surgery to assess sternal healing. Medical records were also retrospectively reviewed to identify perioperative variables associated with poor early sternal healing. Results: (1) After coronary grafting, assessment of sternum showed significant differences in healing between the two groups. (2) Diabetes mellitus as an independent predictor for superficial wound infection. (3) Pedicled procedure is an important factor associated with superficial wound infection in post-operative period. (4) Skeletonized procedure prolong the operation. (5) Pedicled procedure prolong the ICU and hospital stay.Conclusion: (1) Skeletonization of internal thoracic artery conduits lowers the risk of superficial and deep sternal wound infection in patients undergoing CABG with internal thoracic artery grafting. (2) Skeletonization of internal thoracic artery conduits prolong the operation time and require more surgical skills. (3) Skeletonization of ITA has better outcome.

Injection of Bupivacaine into the Pleural and Mediastinal Drains: A Novel Approach for Decreasing Incident Pain After Cardiac Surgery - Montreal Heart Institute Experience.

BackgroundWe conducted a chart review of prospectively collected data in order to demonstrate the safety and efficacy of an innovative technique of pleural and mediastinal drain injections.MethodsPatients who had undergone cardiac surgery and who continued to have pain despite the use of a multimodal pain protocol received injections of 20 mL of 0.25% bupivacaine in pleural and/or mediastinal chest drainage tubes.ResultsPatients were evaluated for the incidence mediastinitis, osteitis, and deep sternal wound infection as well as the speed and intensity of pain relief. The odds ratio of infection in the infused group was 0.955 (CI = 0.4705, 1.9384). The adjusted mean “decrease in pain” was 4.01 (SEM = 0.15 and 95% CI = 3.78, 4.38), using the 11-point Likert Numerical Rating Scale. The mean adjusted “time to maximum pain relief” was 8.33 minutes (SEM = 0.42 and 95% CI = 7.50, 9.15).ConclusionThis technique is a powerful, safe, and efficient tool in the armamentarium of pain management and its growing use within our institution has provided a substantial benefit in the treatment of early post-operative pain.

Bilateral internal thoracic artery grafting in haemodialysis patients with diabetic nephropathy.

To compare postoperative outcomes in patients with diabetic nephropathy receiving haemodialysis and undergoing isolated coronary artery bypass grafting (CABG) using bilateral or single skeletonized internal thoracic artery (ITA). Among 1441 consecutive patients undergoing isolated CABG between 2002 and 2019 at our university hospital, we retrospectively analysed data for 107 patients with diabetic nephropathy receiving haemodialysis. After inverse probability of treatment weighting, we found no statistically significant differences regarding patients' preoperative characteristics. All patients underwent myocardial revascularization using the off-pump technique. There was no statistical significance in postoperative deep sternal wound infection (P = 0.902) and 30-day mortality (P = 0.755). However, the bilateral ITA group had a lower rate of postoperative stroke versus the single group (0% vs 5.5%, respectively; P = 0.021). Follow-up was completed in 95.3% (102/107) of the patients, and the mean follow-up duration was 3.3 years. Thirty-eight deaths occurred in the bilateral ITA group and 18 in the single ITA group. There was no significant difference in all-cause death (P = 0.558) and cardiac death rates (P = 0.727). Multivariable Cox regression models showed that the independent predictors of all-cause death were age [hazard ratio (HR) 1.031; P = 0.010], previous percutaneous intervention (HR 1.757; P = 0.009) and gastroepiploic artery grafting (HR 0.582; P = 0.026). Bilateral ITA grafting in patients with diabetic nephropathy receiving haemodialysis did not improve mid-term outcomes.

The impact of incisional negative pressure wound therapy on the wound healing process after midline sternotomy.

Previous studies have reported that the use of incisional negative pressure wound therapy (INPWT) might reduce the incidence of wound infections, although its mechanism remains unknown. We designed a prospective study to explore the effects of INPWT on different stages of the wound healing process. After meeting the inclusion criteria, 108 patients were enrolled. Based on exclusion criteria four patients were excluded and 104 patients were randomised into two groups. INPWT was applied after primary closure of the midline sternotomy in the study group (n = 52), while conventional wound dressing was applied in the control group (n = 52). We documented the incidence of deep sternal wound infections and analysed the pre‐ and postoperative inflammatory biomarkers and scar size in both groups. No wound infections were observed in the study group compared with six cases (11.1%) in the control group, (P = .026). No significant differences were observed in the inflammatory biomarkers between the groups. Scar size was significantly smaller in the study group. We concluded that INPWT has less effect on the inflammatory phase and appears to have more effect on the proliferation phase through pronounced scar formation.

Antimicrobial prophylaxis in adult cardiac surgery in the United Kingdom and Republic of Ireland.

Deep sternal wound infections are a financially costly complication of cardiac surgery with serious implications for patient morbidity and mortality. Prophylactic antimicrobials have been shown to reduce the incidence of infection significantly. In 2018, the European Association for CardioThoracic Surgery (EACTS) provided clear guidance advising that third-generation cephalosporins are the first-line prophylactic antimicrobial of choice for cardiac surgery via median sternotomy as a result of their broad spectrum of activity and association with reduced postoperative mortality. Despite this guidance, it was believed that UK practice differed from this as a consequence of national concerns surrounding cephalosporins use and Clostridioides difficile infection. A survey was developed and distributed to all UK and Republic of Ireland (ROI) cardiac surgery centres in January 2019 to quantify this variation. Of the 38 centres, 34 responded. Variation existed between the antimicrobial agent used, as well as the dosage, frequency and duration of suggested regimens even among centres using the same antimicrobial agent. The most common antimicrobial prophylaxis prescribed was a combination of flucloxacillin and gentamicin (16, 47%). Followed by cefuroxime (6, 17.6%) and cefuroxime combined with a glycopeptide (4, 11.7%). In patients colonised with methicillin-resistant Staphylococcus aureus or those with penicillin allergy gentamicin combined with teicoplanin was most common (42% and 50%, respectively). This variation in antimicrobial agents and regimens may well contribute to the varying incidence of surgical site infection seen across the UK and ROI.

Recent developments in controlling sternal wound infection after cardiac surgery and measures to enhance sternal healing.

One of the major risks of cardiac surgery is the occurrence of infection at the sternal wound site. Sternal wound infections are primarily classified into superficial infection and deep sternal wound infection or mediastinitis. A patient is diagnosed with mediastinitis if microorganisms are present in their mediastinal tissue/fluid or with the observation of sternal wound infection during operation and with characteristic symptoms including chest pain, fever, and purulent drainage from the mediastinum. It is usually caused by Staphylococcal organisms in 75.8% of cases and the rest is caused by gram-negative bacteria. Currently, in cardiac surgery, hemostasis is achieved using electrocautery and bone wax, and the sternum is closed using wire cerclage. Several studies show that bone wax can act as a nidus for initiation of infection and the oozing blood and hematoma at the site can promote the growth of infectious organisms. Many research groups have developed different types of biomaterials and reported on the prevention of infection and healing of the sternum. These materials are reported to have both positive and negative effects. In this review, we highlight the current clinical practices undertaken to prevent infection and bleeding as well as research progress in this field and their outcomes in controlling bleeding, infection, and enhancing sternal healing.

Effects of platelet-rich plasma on the healing of sternal wounds: A meta-analysis.

Sternal wound infection (SWI) is a devastating complication after cardiac surgery. Platelet-rich plasma (PRP) may have a positive impact on sternal wound healing. A systematic review with meta-analyses was performed to evaluate the clinical effectiveness of topical application of autologous PRP for preventing SWI and promoting sternal wound healing compared to placebo or standard treatment without PRP. Relevant studies published in English or Chinese were retrieved from the Cochrane Central Register of Controlled Trials (The Cochrane Library), PubMed, Ovid EMBASE, Web of Science, Springer Link, and the WHO International Clinical Trials Registry Platform (ICTRP) using the search terms "platelet-rich plasma" and "sternal wound" or "thoracic incision." References identified through the electronic search were screened, the data were extracted, and the methodological quality of the included studies was assessed. The meta-analysis was performed for the following outcomes: incidence of SWI, incidence of deep sternal wound infection (DSWI), postoperative blood loss (PBL), and other risk factors. In the systematic review, totally 10 comparable studies were identified, involving 7879 patients. The meta-analysis for the subgroup of retrospective cohort studies (RSCs) showed that the incidence of SWI and DSWI in patients treated with PRP was significantly lower than that in patients without PRP treatment. However, for the subgroup of randomized controlled trials (RCTs), there was no significant difference in the incidence of SWI or DSWI after intervention between the PRP and control groups. There was no significant difference in PBL in both RCTs and RSCs subgroups. Neither adverse reactions nor in-situ recurrences were reported. According to the results, PRP could be considered as a candidate treatment to prevent SWI and DSWI. However, the quality of the evidence is too weak, and high-quality RCTs are needed to assess its efficacy on preventing SWI and DSWI.

Less stringent perioperative glucose control improves outcomes after coronary artery bypass graft in patients with insulin dependent diabetes mellitus

Abstract Objective After coronary artery bypass grafting (CABG), studies testing strict glycemic control did not took into account previous insulin use. Our aim was to evaluate the effect of perioperative (PO) control in patients with NonDM (ND), noninsulin- (NIDDM) and insulin-dependent (IDDM) diabetes submitted to CABG. Methods We included CABG patients (2010–2017), stratified by DM presence and type. PO glucose was managed with a standardized protocol (IV insulin targeting a glucose &amp;lt;180 mg/dL. Endpoints included in-hospital death, major adverse cardiac and cerebrovascular (MACCE) events, deep sternal wound infection [DSWI], and major infections. PO glucose control was stratified in 4 quartiles using the highest glucose level: 1st, &amp;lt;140mg/dL; 2nd, 140–179mg/dL; 3rd, 180–239mg/dL; and 4th, &amp;gt;240mg/dL). Multivariable analysis was used to model the association of PO glucose control with outcomes, taking the presence and type of DM into account. All analysis on SPSS 23 (SPSS, IBM, 2018), with p&amp;lt;0.05 as statistically significant. Results 2020 CABG pts, age 64±10 y, 31% female, DM 37,5% (66% NIDDM, 34% IDDM). Compared with DM, neither NIDDM nor IDDM were associated with mortality (OR=0.99 [0.61–1.61], p=0.985) or MACCE (OR=0.12 [0.81–1.54], p=0.477). In multivariable analysis, DM (OR=1.58 [1.01–2.49], p=0.049) and IDDM (OR=2.55 [1.57–4.16], p&amp;lt;0.001) were independently associated with DSWI. In a mediation analysis, the inclusion of IDDM in the model, weakened the association of DM with DSWI into nonsignificance (OR=1.20 [0.73–1.98], p=0.456), while IDDM retained significant association with DSWI (OR=2.37 [1.39–4.01], p=0.001), indicating that the impact of DM on the incidence of DSWI is fully explained by the IDDM patients. Poor PO glycemic control was an independent predictor of death (OR=1.09, 95% CI 1.04–1.13, p&amp;lt;0.001; 9% higher mortality to each 10mg/dL increase). Accordingly, patients from ND group in the highest stratum of glucose control (4th quartile), compared with the other 3 quartiles, showed increased mortality (3.8%, 2.9%, 4.4%, and 17.9%, p&amp;lt;0.001) and MACCE (8.7%, 8.5%, 14.3%, and 39.3%, p&amp;lt;0.001). However, in IDDM patients, poor PO glycemic control was not an independent predictor of mortality (OR=3.34, 95% CI 0.34–38.23, p=0.347). In fact, strict PO glycemic control in IDDM patients (but not in ND and NIDDM) increased the incidence of DSWI (&amp;lt;140mg/dL, 19.8%, vs &amp;gt;240mg/dL, 8.2%, p=0.015) and other major infections (&amp;lt;140mg/dL, 26.2%, vs &amp;gt;240mg/dL, 12.2%, p=0.048). Conclusion After CABG, poor glycemic control is an independent predictor of mortality. However, in IDDM patients, PO hyperglycemia is not associated with mortality, and strict glycemic control increased DSWI, major infections and LOS in these patients. These results suggest that IDDM patients submitted to CABG may benefit from less stringent glycemic targets in PO management. Funding Acknowledgement Type of funding source: None