Median Sternotomy For Cardiac Surgery Research Articles

Negative microbiological results are not mandatory in deep sternal wound infections before wound closure

To define the outcome of treatment for deep sternal wound infections (DSWIs) using direct wound closure (DC) or vacuum-assisted therapy (VAT) based on negative vs. positive microbiological results. Between 1999 and 2008, 7746 patients underwent median sternotomy for cardiac surgery at our institution. Patients were screened for DSWI and out of the cohort 159 were identified (2%). These patients were treated, either using DC or VAT with delayed wound closure. Outcomes were retrospectively analysed to determine the effect of negative cultures at the time of closure. The indication for sternotomy was CABG 51%, isolated valve 18%, CABG/valve 18% and other related cardiovascular procedures 14%. Sixty-five percent of the wound infections was diagnosed during rehabilitation period. One hundred and five (66%) patients were treated with VAT vs. 54 (34%) patients with direct closure. Coagulase negative staphylococci were found in 48% of bacterial cultures. In 75% of the patients, the microbiological results were positive at time of wound closure (69.2% VAT vs. 87.0% direct closure, P = 0.014). Out of 159 patients, 5.0% were with positive microbiological results at the time of closure readmitted vs. 5.1% with negative microbiological results (P = 1.0). Patients with VAT stayed significantly longer in the hospital (mean 21 ± 16 vs. 13 ± 12, P = 0.002). Negative microbiological results are not mandatory before wound closure, as the rate of readmissions for recurrence of infection showed no difference between groups. Our results also suggest that shortening of VAT despite positive microbiological results may be feasible.

Laser Doppler flowmetry assessment of peristernal perfusion after cardiac surgery: beneficial effect of negative pressure therapy

Negative pressure therapy has been successfully applied to clean, closed incisions in patients at high-risk for wound complications. Using laser Doppler flowmetry, we evaluated peristernal perfusion after cardiac surgery via median sternotomy, assessing the influence of mammary artery harvesting and the impact of negative pressure therapy. Twenty adult patients underwent median sternotomy for cardiac surgery followed by routine closure. Negative pressure was applied at 125 mm Hg for 4 days postoperatively in patients with increased risk for wound complications (n = 10, negative pressure group); standard dressings were applied to control incisions postoperatively (n = 10). Presternal perfusion was determined at baseline and daily for 4 days postoperatively using laser Doppler flowmetry. Results within and between groups were compared with analysis of variance. No wound complications were encountered in either group. Perfusion increased among the patients who underwent negative pressure therapy and decreased among the controls (P = 0.004). Mammary artery harvesting reduced peristernal perfusion by 25.7% in the controls, but negative pressure increased perfusion by 100% after mammary harvesting (P = 0.04). Negative pressure therapy increased perfusion relative to controls and compensated for reduced perfusion rendered by mammary artery harvesting, providing additional support for 'well wound therapy' in high-risk patients.

Figure-of-Eight vs. Interrupted Sternal Wire Closure of Median Sternotomy

Sternal dehiscence is a rare but devastating complication following median sternotomy for cardiac surgery. The optimal technique for sternal closure is unclear. We conducted this prospective randomized trial to compare the incidence of sternal dehiscence after figure-of-8 and simple interrupted suturing in patients undergoing coronary artery bypass grafting. Between January 2007 and June 2008, 98 patients had figure-of-8 suturing and 97 had interrupted sutures. The mean age of the patients was 60.9 +/- 7.6 years. The overall sternal dehiscence rate was 8%; 7 cases in the in figure-of-8 group and 9 in the interrupted group. Thirteen patients had no wound infection and healed with conservative treatment. Only 3 patients had sternal dehiscence with infection: 2 with simple interrupted closure and 1 with figure-of-8 sternal closure. There was no significant difference in rates of sternal dehiscence between the 2 groups. It was concluded that figure-of-8 sternal suturing is equally effective as simple interrupted suturing in preventing sternal dehiscence.

Sternal Weave in High-Risk Patients to Prevent Noninfective Sternal Dehiscence

Dehiscence of the sternum is a serious and potentially devastating complication. The purpose of this prospective study was to determine whether a prophylactic sternal weave would decreased the incidence of noninfective sternal dehiscence, compared to routine sternal closure, in a high-risk group. Between 2000 and 2007, 200 patients undergoing median sternotomy for cardiac surgery, with one or more risk factors including New York Heart Association functional class III/IV, chronic obstructive pulmonary disease, osteoporosis, obesity, and off-midline sternotomy, were randomly assigned to group A (sternal weave closure, 100 patients) or group B (routine sternal wire closure, 100 patients). No patient in either group with a single risk factor had sternal dehiscence. The incidence of noninfective sternal dehiscence was significantly less in group A than group B in patients with 2 or more risk factors (2.5% vs. 12.5%). Routine sternal closure is sufficient in patients with a single risk factor, whereas a prophylactic sternal weave should be carried out in all patients with 2 or more risk factors, to decrease postoperative morbidity.

Chronic Expanding Hematoma in Sternum Resected 5 Years After Median Sternotomy

Chronic expanding hematomas occur at various locations in the body; however, their occurrence in the sternum has not been reported yet. We report a patient with chronic expanding hematoma in the sternum 5 years after undergoing a median sternotomy for cardiac surgery. Although preoperative biopsy specimens did not lead to a definitive diagnosis, we could not rule out the possibility of a malignant tumor because of the expanding and infiltrative behavior of the hematoma. We performed a sternectomy and reconstructed the chest wall using artificial materials.

Omental Transposition: The Final Solution for Major Sternal Wound Infection

Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.

Trunk stabilisation exercises reduce sternal separation in chronic sternal instability after cardiac surgery: a randomised cross-over trial

Do trunk stabilisation exercises reduce sternal separation and pain, and improve the quality and control of the performance of tasks in individuals with chronic sternal instability? Randomised crossover study with concealed allocation and intention-to-treat analysis. Nine individuals with chronic sternal instability following a median sternotomy for cardiac surgery. The experimental intervention consisted of six weeks of trunk stabilisation exercises; the control intervention was no exercises. Outcomes were sternal separation measured by ultrasound in mm, pain during the performance of nine everyday tasks measured on a 100-mm visual analogue scale, and the quality and control of the performance of two tasks scored on a 100-mm visual analogue scale. Overall, sternal separation during the period of trunk stabilisation exercises decreased by 6.2 mm (95% CI 3.5 to 8.9) more than during the control period. Overall, pain decreased when performing everyday tasks by 14 mm (95% CI 5 to 23) more than during the control period. Overall, task performance during the period of trunk stabilisation exercises did not improve (mean difference 10 mm, 95% CI -3 to 22) more than during the control period. Trunk stabilisation exercises should be included in the rehabilitation of individuals who experience sternal instability following cardiac surgery. A larger trial is warranted to determine if stabilisation exercises are beneficial in improving the quality and control of task performance.

Der Stellenwert der V.A.C.®-Therapie in der plastischen Deckung von fortgeschrittenen Sternumosteomyelitiden

Since its introduction in 1997 the vacuum assisted closure therapy has gained widespread and is for its indications international accepted. It is also well established in the treatment of sternal infections a dreaded complication after median sternotomy in cardiac surgery. The well known positive effects of the vacuum therapy act as a dignified cleaning procedure between debridement and plastic coverage or as a temporarily closure method if the first debridement was properly not sufficient. Between January 2003 and December 2005 twenty eight patients with advanced sternal infection after median sternotomy were treated by radical debridement, vacuum assisted closure therapy and definitive plastic coverage by muscle flaps. In this article three patients are exemplarily introduced. In all patients a sufficient plastic coverage was achieved after radical debridement an vacuum assisted closure therapy. The patients received a pedicaled muscle flap. Stable wound condition with no signs of a recurrent sternal infection were observed in all patients. Vacuum assisted closure therapy acts as a link between radical Debridement and definitive plastic coverage in prolonged sternal infection after median sternotomy. Before the invention of V.A.C.(R) dressing changes were obliged every day in patients with deep sternal infection. The V.A.C.(R) therapy reduces the frequency of this painful dressing changes significantly and on this behalf makes life more comfortable for this mostly multi-morbid patients.

Rapid serodiagnosis of Staphylococcus aureus surgical site infection following median sternotomy

To determine the sensitivity and specificity of a novel ELISA for the serodiagnosis of surgical site infection (SSI) due to staphylococci following median sternotomy. Twelve patients with a superficial sternal SSI and 19 with a deep sternal SSI due to Staphylococcus aureus were compared with 37 control patients who also underwent median sternotomy for cardiac surgery but exhibited no microbiological or clinical symptoms of infection. A further five patients with sternal SSI due to coagulase-negative (CoNS) staphylococci were studied. An ELISA incorporating a recently recognised exocellular short chain form of lipoteichoic acid (lipid S) recovered from CoNS, was used to determine serum levels of anti-lipid S IgG in all patient groups. Serum anti-lipid S IgG titres of patients with sternal SSI due to S. aureus were significantly higher than the control patients (P<0.0001). In addition, patients with deep sternal SSI had significantly higher serum anti-lipid S IgG titres than patients with superficial sternal SSI (P = 0.03). Serum anti-lipid S IgG titres of patients with sternal SSI due to CoNS were significantly higher than the control patients (P = 0.001). The lipid S ELISA may facilitate the diagnosis of sternal SSI due to S. aureus and could also be of value with infection due to CoNS.

Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial

Objective: We sought to determine whether a continuous regional infusion of a local anesthetic delivered to the operative site would result in decreased levels of postoperative pain and narcotic requirements for patients who undergo a standard median sternotomy for cardiac surgery. Methods A double-blind, randomized, controlled trial was conducted at a single center. Patients who were undergoing elective coronary artery bypass graft surgery alone or combined with laser transmyocardial revascularization received bilateral intercostal nerve blocks with either ropivacaine or saline. At wound closure, 2 catheters with multiple side openings were inserted percutaneously and placed directly over the sternum. The same agent (ropivacaine vs saline) was then administered as a continuous regional infusion for 48 hours through an elastomeric pump. Requirements for postoperative systemic narcotic analgesics and pain assessment scores were recorded for 72 hours after the operation. Secondary outcome measures were hospital length of stay and pulmonary function test results. Pain scores and narcotic use on the second postoperative day were also compared to avoid the confounding influence of anesthesia administered at the time of the operation. Results The total amount of narcotic analgesia required by the ropivacaine group was significantly less than that of the control group (47.3 vs 78.7 mg, respectively; P = .038). The ropivacaine group required less narcotics on postoperative day 2 as well (15.5 vs 29.4 mg, P = .025). The mean overall pain scores for the ropivacaine group were significantly less than the mean overall scores for the normal saline group (1.6 vs 2.6, respectively; P = .005). Patients receiving ropivacaine had a mean length of stay of 5.2 days compared with 8.2 days for patients in the normal saline group ( P = .001). Excluding the data from outliers (length of stay = 39 days), the normal saline group mean length of stay was 6.3 days ( P < .01). There was no difference in assessment of pulmonary function. Conclusion Continuous delivery of local anesthetics significantly improved postoperative pain control while decreasing the amount of narcotic analgesia required in patients who underwent standard median sternotomy. There was also a significant decrease in hospital length of stay, which is likely to result in significant cost reductions.

Mediastinoscopy and mediastinotomy after cardiac surgery: are safety and efficacy affected by prior sternotomy?

Background The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown. Methods We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001. Results During this period 28 patients (25 male and 3 female; mean age, 63 ± 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 ± 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n = 22; left anterior mediastinotomy, n = 7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n = 6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n = 10; lymphoma, n = 3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n = 1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications. Conclusions Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.

Does the time of resternotomy for bleeding have any influence on the incidence of sternal infections, septic courses or further complications?

Former studies on sternal wound infections indicate predisposing factors like diabetes, obesity, use of bilateral internal mammary grafts, impaired renal function and reoperation. We wanted to evaluate whether the time of resternotomy for postoperative bleeding has any influence on the development of a sternal wound infection and other complications. In our department, 12,315 patients underwent median sternotomy for cardiac surgery between 1987 and 1998. We analyzed the clinical data of all patients which were reoperated on for postoperative bleeding, especially patients with subsequent operations caused by sternal wound infections. All data were compared by T-test respectively chi2-test, and p<0.05 was regarded as significant. 406 of the 12,315 patients were re-explored because of postoperative bleeding (3.3%). 57 (14%) of these patients died in the postoperative period of non-infectious complications. The remaining patients were divided into two groups: Group A (286 patients) (70.4%) did not suffer from any sternal wound complications, where as group B patients (n = 63) (15.6%) needed subsequent surgery due to sternal infection. There were no significant differences in either concerning age, clinical data and first operation. All patients had an average blood loss of 223 ml/hr. The time before re-operation for bleeding was 5.3+/-1.7 hours in group A compared to 11.1+/-4.2 hours in group B (p<0.05). A significant delay of reoperation for bleeding could also be found for patients with postoperative septic complications (ø: 5.2+/-1.9 hours, +: 12.9+/-5.2 hours), renal failure, mechanical ventilation >48 hours and a stay in hospital >20 days. Early reoperation for postoperative bleeding decreases the number of subsequent complications, e.g. sternal wound infections, septic complications and prolonged mechanical ventilation.

Simple pectoralis major myocutaneous advancement flaps for closure after sternal wound dehiscence

Between October 1994 and March 1996, 14 consecutive patients with a wound dehiscence after median sternotomy for cardiac surgery were treated with pectoralis major myocutaneous advancement flaps. After thorough sternal wound debridement, the sternal edges were contoured to create a shallow defect. This was to enable the obliteration of dead space between the mediastinum and the flaps. The pectoralis muscle was then elevated off the chest wall, its humeral attachment, the thoraco-acromial pedicle and the connection with the skin were left intact. Next, the bilateral myocutaneous flaps were advanced medially and approximated to each other in the midline. The mean operation time was 140 min and the mean follow-up time was 10 months. Four patients developed minor complications. The advantage of this technique is its simplicity and the reduction in mean operation time.

Heterotopic calcification in abdominal wounds

Background Heterotopic bone formation in abdominal incisions is a recognized but uncommon sequela of abdominal surgery. The condition of heterotopic bone formation in the abdominal scar may not only cause physical and/or emotional discomfort for the patient but also mimic a retained foreign body or recurrence of a malignant condition. All cases of two surgeons representing a wide variety of general and thoracic surgery were reviewed, and three primary cases and one recurrent case of heterotopic bone formation in an abdominal wound were identified. These cases are compared with the cases available in the English literature to enhance the recognition, appropriate diagnosis, and treatment options available for the patient with this unusual condition. Methods All cases for two surgeons representing a variety of general and thoracic surgery were reviewed. Three patients with painful heterotopic calcification of an abdominal incision requiring excision were identified. One patient had undergone an upper midline laparotomy for pancreatitis and the other two had undergone median sternotomy for cardiac surgery. One of these patients developed a painful recurrence of upper linea alba calcification. All patients were male and ranged in age from 51 to 74 years. Primary heterotopic calcification of the upper linea alba occurred between 2 and 4 months for all patients. All cases were treated with excision and primary tissue closure. The case of recurrent calcification occurred 11/2 months after primary closure, and was treated with re-excision and 1,200 centirads of postoperative radiotherapy to the incision area over 3 days, starting on postoperative day 1. The 2 cases of primary heterotopic calcification successfully treated with the initial excision have been followed for 2 and 6 years respectively without recurrence. The case of recurrent heterotopic calcification treated with re-excision and postoperative radiotherapy has been followed for 10 months without recurrence.

Brachial Plexus Lesions Following Median Sternotomy in Cardiac Surgery

The incidence of neurological deficits of the upper extremity was studied in a prospective trial on 201 consecutive patients who underwent median sternotomy at cardiac surgery. In 13 patients (6.5%), a brachial plexus paresis was diagnosed postoperatively. We were unable to demonstrate any statistically significant correlation between brachial plexus paresis and the side of arm placement, the side of cannulation of the jugular vein, the duration of operation, the bypass time, sex, or type of operation. All patients who suffered from neurological deficit were aged 50 years and more, however without any statistically significant correlation. In our opinion, brachial plexus lesions following median sternotomy in cardiac surgery depend on the extent of sternal spread and the height of placement of the retractor in dependence of the rigidity of the rib cage. By reason of the iatrogenic cause of brachial plexus lesions, it appears to us that these complications should be included in those of which the patient needs to be informed preoperatively.

Brachial Plexus Lesions following Median Sternotomy in Cardiac Surgery

The incidence of neurological deficits of the upper extremity was studied in a prospective trial on 201 consecutive patients who underwent median sternotomy at cardiac surgery. In 13 patients (6.5%), a brachial plexus paresis was diagnosed postoperatively. We were unable to demonstrate any statistically significant correlation between brachial plexus paresis and the side of arm placement, the side of cannulation of the jugular vein, the duration of operation, the bypass time, sex, or type of operation. All patients who suffered from neurological deficit were aged 50 years and more, however without any statistically significant correlation. In our opinion, brachial plexus lesions following median sternotomy in cardiac surgery depend on the extent of sternal spread and the height of placement of the retractor in dependence of the rigidity of the rib cage. By reason of the iatrogenic cause of brachial plexus lesions, it appears to us that these complications should be included in those of which the patient needs to be informed preoperatively.

Hemodynamic Compromise Associated with Air Trapping Following Coronary Artery Bypass Surgery

Cardiovascular collapse due to pulmonary hyperinflation was noted in a patient with chronic obstructive pulmonary disease following median sternotomy for cardiac surgery. Treatment included bronchodilator therapy to reduce airway obstruction, limitation of minute ventilation, and increasing time available for exhalation. High inspiratory flow rates and expiratory retard may be beneficial.

Brachial plexus injury after median sternotomy.

Five patients are described with brachial plexus injuries complicating median sternotomy for cardiac surgery. The lower roots (medial cord) of the plexus were most affected and in some cases the lesions were bilateral. Pain was a prominent feature and although motor and sensory symptoms both occurred, motor signs were more prominent than objective sensory loss. Recovery was protracted and sometimes incomplete. Traction or compression of the plexus (or both) are the major possible mechanisms of injury; our experience and that of others suggests that traction is the more probable mechanism.