Post-sternotomy Patients Research Articles

Characterization of the substernal space with computed tomography imaging in patients with and without median sternotomy: Assessing a novel implant location for extravascular defibrillation lead placement.

Implantable cardioverter-defibrillators (ICDs) provide clinically significant therapy for the prevention of sudden cardiac death. This study aimed to characterize the substernal space using computed tomography (CT) in patients with and without prior midline sternotomy to investigate the feasibility of substernal ICD lead implantation in post-sternotomy patients. High-quality electrocardiogram-gated CT images from 100 patients (71% male, average body mass index 23.5±2.9) were retrospectively collected, including 50 patients with prior midline sternotomy (S-group) and 50 patients with no prior sternotomy (NS-group). Distances were measured from the retrosternal surface to the epicardial surface of the heart and segmented into four regions from the xiphoid tip and superiorly along the sternum. Results generally showed a measurable but narrower average sternum-to-heart distance in the prior sternotomy group compared to the non-sternotomy group in all four regions (p<.05). In the S-group, the sternum-to-heart distances across all regions ranged from 0 to 32.0mm, while in the NS-group, the distances ranged from 0 to 39.9mm. Small but measurable separations between the heart and sternum were observed in patients with prior sternotomy, particularly near the xiphoid region, indicating the potential viability of extravascular substernal ICD lead implantation in post-sternotomy patients.

Comparison of postoperative exercise capacity of patients who underwent sternal closure with SternaLock Blu and those with traditional sternal wire closure following cardiovascular surgery via sternotomy

PurposeThis study aimed to evaluate the efficacy of postoperative exercise capacity of SternaLock Blu (Zimmer Biomet, USA) for post-sternotomy patients who underwent cardiovascular surgery.MethodsWe investigated 116 patients, including 35 women (mean age 70.3 ± 10.0 years), who underwent cardiovascular surgery by median sternotomy. Patients were candidate for using SternaLock Blu, such as obesity (body mass index > 30/kg/m2), insulin-dependent diabetes mellitus, steroid administrating, undergoing coronary bypass artery grafting used bilateral internal thoracic artery. These patients were categorized into those with SternaLock Blu (S group, n = 47) or with sternal wires only (N group, n = 69) for closing sternotomy, and their data were analyzed.ResultsMax Prince Henry Pain Scale (PHPS) was significantly low in the S group than in the N group (N vs. S = 2.7 ± 1.4 vs. 1.6 ± 1.7%, p < 0.001). Postoperative 6-min walk was significantly longer in the S group than in the N group (N vs. S = 346.2 ± 101.6 vs. 408.6 ± 104.6 m, p = 0.018). The length of intensive care unit (N vs. S = 4.9 ± 0.9 vs. 4.0 ± 1.2 days, p < 0.001) and hospitalization (N vs. S = 18.0 ± 5.0 vs. 15.2 ± 3.8 days, p = 0.006) were significantly shorter in the S group than in the N group.ConclusionsSternaLock Blu could keep exercise capacity, and might help reduce postoperative pain and medical treatment period for patients who underwent cardiovascular surgery.

Efficacy of Myofascial Release on Pain and Pulmonary Function during First Phase of Cardiac Rehabilitation - An Evidence Based Study

Background: Cardiovascular disease includes disease of heart and blood vessels. It is most common causes of mortality around the globe as well as in India.[1],[2] Cardiac rehabilitation and secondary prevention programs aim to improve all lifestyle habits, quality of life and physical and psychological function. However, surgical procedures like coronary artery bypass grafting have some complications. They may affect different systems but most frequent Complications are pulmonary complications. As a result of Surgical trauma in highly vascularised and innervated pleura and chest wall, severe pain after sternotomy occurs. which will cause weakens the respiratory muscles, reduces chest expansion, glenohumeral joint and spine mobility, as well as lessen expectoration of secretions. Purpose: To provide an overview of current evidence with respect to: Effect of manual therapy (OMT, MFR) in post sternotomy acute and chronic pain. Immediate effect of manual therapy pulmonary system. Effect of manual therapy functional recovery and length of hospital stay, reduce analgesia consumption, improve ROM. Effect of MFR on pulmonary function. Methodology: ➢ Search engines used were: • Google scholar • PubMed • PEDro • ScienceDirect • ResearchGate ➢ Key words used were: • Sternotomy • Post sternotomy pain • Pulmonary function • Myofascial release • OMT • Respiratory function and sternotomy Total 10 studies were selected. Results: Evidences were reviewed and analysis was done. Articles shows that MFR reduce post-operative pain, improve respiratory function, reduces length of stay and dose of analgesia consumption. Conclusion: Based on evidences, it is reviewed that MFR and manual therapy is beneficial in seance of reducing pain and improving pulmonary function in post sternotomy patients. Keywords: Sternotomy, Post sternotomy pain, Pulmonary function, Myofascial release, OMT, Respiratory function and sternotomy.

B-AB10-01 INAPPROPRIATE SUBCUTANEOUS DEFIBRILLATOR SHOCKS IN A PATIENT WITH A STERNAL ABSCESS

Inappropriate shocks from a subcutaneous defibrillator (S-ICD) cause significant morbidity. We present a rare case of inappropriate S-ICD shocks due to oversensing in a patient with a sternal abscess. N/A A 29 year old female with a history of endocarditis requiring aortic and mitral valve replacement, tricuspid valve repair, and VT arrest underwent S-ICD implant one year ago. She presented with recurrent endocarditis and sepsis. During her hospital course, she had multiple ICD shocks, which were found to be inappropriate on device interrogation. Tachycardia therapies were disabled. S-ICD sensing configuration had been set to the secondary vector per the automatic programming algorithm. There was oversensing in secondary (tip to can) and alternate (tip to ring) sensing configurations (Figure 1A), but none in the primary (ring to can) sensing vector. A Chest CT scan revealed a fluid collection at the anterior sternum surrounding the S-ICD lead and osteomyelitis (Figure 1B, 1C). She developed complete heart block and underwent sternal debridement, valve surgery, and S-ICD explant. She subsequently received a transvenous bi-ventricular ICD after appropriate antimicrobial therapy. To our knowledge, this is the first reported case of a sternal abscess involving the distal parasternal sensing electrode of an S-ICD causing oversensing and leading to inappropriate shocks. Awareness of this risk, especially in post-sternotomy patients, is important in the management of S-ICD malfunction.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis

Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P< .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P= .40). In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

Wearable Sensor-Based Digital Biomarker to Estimate Chest Expansion During Sit-to-Stand Transitions-A Practical Tool to Improve Sternal Precautions in Patients Undergoing Median Sternotomy.

Sternal precautions are a universal part of the discharge education for post-sternotomy patients to reduce the risk of sternal complications. However, they are always designed based on physical therapists' or surgeons' subjective judgment without any objective evidence. Thus, they could be overly restrictive to hinder the patients' recovery, physically and psychologically. To fill this gap, this paper proposes a digital biomarker to estimate chest expansion during sit-to-stand transitions based on wearable inertial sensing and data fusion technologies. First, we carried out bench tests to evaluate the reliability of the digital biomarker to represent relative sensor rotation. We also verified effectiveness of this digital biomarker to detect subtle skin extension in proactive chest expansion trials by 11 healthy volunteers. Then, we measured the digital biomarker during sit-to-stand transitions with different strategies and some daily routine activities (walking, sitting, and standing) performed by the healthy volunteers and 22 post-sternotomy patients. The comparison between these measurements evaluated the effectiveness of several known guidelines of sternal precautions for sit-to-stand transitions. The results showed that first, pushing up from a chair by taking support from armrests induced larger chest expansion ( p = 0.009 ) compared with sit-to-stand transition while keeping the arms relaxed; second, crossing the arms or hugging a pillow can help reduce chest expansion ( ) compared with keeping the arms relaxed during sit-to-stand transitions; third, pushing up while taking support from a frontal support (e.g., table or walker) induced the same level of chest expansion ( ) as that during sit-to-stand transition while keeping the arms relaxed.

The impact of deep sternal wound infections treated by negative pressure on early, 1 year and late mortality: A longitudinal case-control study.

Deep sternal wound infection (DSWI) after cardiac surgery, is a rare complication that can be fatal. Due to a lack of available data, we compared early in-hospital, 1-year and long-term mortality in patients with DSWI. Patients undergoing any type of cardiac surgery, in the Cardiothoracic Surgery Department of G. Papanikolaou Hospital, between May 2012 and December 2016, were investigated. All patients who developed DWSI postoperatively, treated with negative pressure wound therapy (NPWT), were included in the group of cases. A random population from the rest of the patients was selected in a 1:2 ratio, representing controls. From a total of 2104 patients, 80 patients (3.8%) developed DSWI (cases group), whereas 180 patients were randomly selected as controls. Early (within 30 days) mortality was significantly higher in the DSWI group compared with controls (15% vs 3.9%, respectively; P = .002). Similarly, more deaths occurred in the cases group compared with controls during the follow-up (ie, 19 vs 12, respectively; P < .001); the majority of deaths (84.2%) occurred within the first year. Long-term survival did not differ between the two study groups during follow-up (median duration = 1072 vs 1022 days for cases and controls, respectively). DSWI significantly increased early and 1-year mortality in poststernotomy patients treated with NPWT compared with those not developing this complication. However, long-term survival was similar between the two study groups, thus highlighting the beneficial effect of NPWT in terms of clinical outcomes in patients with DWSI.

KEEP YOUR MOVE IN THE TUBE: BREAKING DOWN THE RESTRICTED WALLS OF MOVEMENT POST-STERNOTOMY

A major objective of undergoing cardiac surgery is to return to best possible function. However, functional activity is limited in the majority of patients, often up to 12-weeks post-operatively, because patients are asked to use sternal precautions. An alternative, evidence-based, approach is needed. We aim to prospectively compare patient oriented and safety outcomes using traditional sternal precautions relative to a newly adopted movement strategy called Keep Your Move in the Tube (KYMITT), in post-sternotomy patients. A before/after cohort design will be used. The first 100 patients will receive sternal precautions instructions. Following a 4-week washout and staff instruction period, 100 patients will receive instructions using the KYMITT strategy. The primary outcome of interest will be return to function. Other outcomes will include: pain, discomfort, wound healing, pain medication use, antibiotic use, and health services use. Follow-up will occur over 12-weeks. One hundred patients have been entered into the traditional sternal precautions group and 100 will be entered into the KYMITT strategy group. Data collection will be complete by July, 2019. Differences between the traditional sternal precautions and KYMITT strategy groups in function over time will be undertaken using unadjusted and adjusted multivariable regression modeling. Other outcomes will be analyzed similarly. The results of this study should confirm that KYMITT is a useful clinical movement strategy for post-sternotomy patients. The clinical implications may include: better return to function for the recovering patient; less onus on the caregiver/family members to assist the patient with movement; and less musculoskeletal injuries for clinical staff.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Topical Lidocaine Patch for Postthoracotomy and Poststernotomy Pain in Cardiothoracic Intensive Care Unit Adult Patients.

Transdermal lidocaine patches have few systemic toxicities and may be useful analgesics in cardiac surgery patients. However, few studies have evaluated their efficacy in the perioperative setting. Objective To compare the efficacy of topical lidocaine 5% patch plus standard care (opioid and nonopioid analgesics) with standard care alone for postthoracotomy or poststernotomy pain in adult patients in a cardiothoracic intensive care unit. A single-center, retrospective cohort evaluation was conducted from January 2015 through December 2015 in the adult cardiothoracic intensive care unit at a tertiary academic medical center. Cardiac surgery patients with new sternotomies or thoracotomies were included. Patients in the lidocaine group received 1 to 3 topical lidocaine 5% patches near sternotomy and/or thoracotomy sites daily. Patches remained in place for 12 hours daily. Patients in the control group received standard care alone. The primary outcome was numeric pain rating for sternotomy/thoracotomy sites. Secondary outcomes were cardiothoracic intensive care unit and hospital lengths of stay and total doses of analgesics received. Forty-seven patients were included in the lidocaine group; 44 were included in the control group. Mean visual analogue scores for pain did not differ between groups (lidocaine, 2; control, 1.9; P = .58). Lengths of stay were similar for both groups (cardiothoracic intensive care unit: lidocaine, 3.06 days; control, 3.11 days; P = .86; hospital: lidocaine, 8.26 days; control, 7.61 days; P = .47). Adjunctive lidocaine 5% patches did not reduce acute pain in postthoracotomy and post-sternotomy patients in the cardiothoracic intensive care unit.

Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery.

To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes. In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively. Overall 105 patients (82% men; 67.0 ± 10.3years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X2 = 17.9; p < 0.001; AUC, 0.83 vs. 0.73). The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP. • Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.

Laryngeal mask airway versus endotracheal tube for percutaneous dilatational tracheostomy in critically ill adults.

Percutaneous dilatational tracheostomy (PDT) is one of the most common bedside surgical procedures performed in critically ill adults, on intensive care units (ICUs), who require long-term ventilation. PDT is associated with relevant life-threatening complications: Cuff rupture or accidental extubation may lead to hypoxia, aspiration or loss of airway. Puncture of the oesophagus, or creating a false passage during dilatation or replacement of the tracheostomy tube, can lead to pneumothorax or emphysema. Wound infections may occur which can cause mediastinits, especially after creation of false passage or in early tracheotomized post-sternotomy patients after cardiac surgery. During the procedure, the patient's airway can be secured with an endotracheal tube (ETT) or a laryngeal mask airway (LMA). This is an updated version of the review first published in 2014. To assess the safety and effectiveness of LMA versus ETT in critically ill adults undergoing PDT on the ICU. We searched the following databases to 9 January 2018: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase. We searched for reports of ongoing trials in the metaRegister of Controlled Trials (mRCT). We handsearched for relevant studies in conference proceedings of five relevant annual congresses. We contacted study authors and experts concerning unpublished data and ongoing trials. We searched for further relevant studies in the reference lists of all included trials and of relevant systematic reviews. We included randomized controlled trials (RCTs) that compared use of laryngeal mask airways versus endotracheal tubes in critically ill adults undergoing elective PDT in the ICU, without injuries to or diseases of the face or neck. We imposed no restrictions with regard to language, timing or technique of PDT performed. Two review authors independently assessed the eligibility and methodological quality of each study and carried out data extraction. Our primary outcomes were all-cause mortality, procedure-related mortality and tally of participants with one or more serious adverse events. Where possible, we combined homogeneous studies for meta-analysis. We used Cochrane's 'Risk of bias' tool and used GRADE to assess the quality of evidence for key outcomes. We included nine RCTs in this review involving 517 participants.Studies had a high or unclear risk of bias. The main reason for this was low methodological quality or missing data, even after study authors were contacted. Study size was generally small, with a minimum of 40, and a maximum of 73 participants.In one study (40 participants), three deaths in the LMA group and two deaths in the ETT group were reported, although none of the deaths were related to the procedure (very low-quality evidence).Five studies (281 participants) reported on procedure-related deaths, stating that no procedure-related death occurred at all (very low-quality evidence).It is uncertain whether there is a difference in the number of people experiencing one or more serious adverse event(s) between LMA and ETT (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.41 to 1.80; 467 participants, 8 studies, very low-quality evidence).The duration of the procedure may be shorter in the LMA group (mean difference (MD) -1.46 minutes, 95% CI -1.92 to -1.01 minutes; 6 studies, 324 participants, low-quality evidence).However failure of procedure, as allocated by randomization, requiring conversion to any other procedure, may be higher in the LMA group (RR 2.82, 95% CI 1.22 to 6.52; 8 studies, 439 participants, low-quality evidence).We did not find any clear evidence of a difference between ETT and LMA groups for all other outcomes. Only one study provided follow-up data for late complications related to the intervention, showing no clear evidence of benefit for any treatment group. Evidence on the safety of LMA for PDT is too limited to allow conclusions to be drawn on either its efficacy or safety compared with ETT. Although the LMA procedure may shorten the period during which the airway is insecure, it may also lead to higher conversion rates. Also, late complications have not been investigated sufficiently. These results are primarily based on single-centre trials with small sample sizes, and therefore the level of evidence remains low. Studies with low risk of bias focusing on late complications and relevant patient-related outcomes are necessary for definitive conclusions on safety issues related to this procedure. The dependency of the successful placement of a LMA on the type of LMA used should also be further assessed.There are two studies awaiting classification that may alter the conclusions once assessed.

Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis

Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition.Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC).Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days.Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.

Early management of deep sternal wound infections using omental flaps

BackgroundDeep sternal wound infections (DSWI) are a grave complication that occurs in 0.3%–5% of post-sternotomy patients. In the meantime, there is no consensus over the most appropriate surgical management for sternal wound infections, following open heart surgery. In this retrospective study, we aimed to evaluate the early versus late use of omental-flaps for DSWI and mediastinitis. MethodsThis retrospective study included patients with DSWI following open cardiac surgeries with variable risk factors, degrees of infection and timing of management. The omental-flap was obtained from the greater omentum and transposed into the pleural cavity through a diaphragmatic incision. ResultsOut of the 15 enrolled patients, seven (46.6%) were diabetics and eight (53.3%) had chronic obstructive pulmonary disease. The severe form of mediastinitis occurred with gram-negative infections due to endotoxemia, as well as with resistant infections as methicillin-resistant staph aureus. Eleven patients had a primary omental-flap coverage after debridement (group I), while the other four underwent sternal rewiring, followed by omental-flap coverage (group II). Only three patients (27.2%) in group I died post-operatively, compared to four patients (100%) in group II. Among group I patients, eight had an early omental-flap coverage (IA), while three had a late coverage (IB). Only two patients died after early management, while five out of the seven (71.4%) patients (groups IB and II) died. ConclusionsEarly management of mediastinitis through omental-flaps has a better prognosis than rewiring. This should include a high index of clinical suspicion and a close post-operative follow-up of clinical manifestations.

Sternal Steel Wire Induced Persistant Intermittan Mediastinal Wound Drainage After CABG

Delayed mediastinal wound drainage due to hypersensitivity to stainless steel sternal wire is very rare conditions in post sternotomy patients. In literature, although some cases reported about treatment by removing the sternal wires because of persistant chest pain due to hypersensitivity, it is rarely reported about conditions that persistant wound drainage from sternal incision due to reactions to strnal wires. We present such a complicated case about these who developed tissue overgranulation and sternal dehiscence and persistent intermittant sternal wound drainage for about twelve months after emergency coronary artery bypass. Repeated wound cultures were negative and no laboratory evidence was founded indicating mediastinitis. We believe there are no previously published papers in literature describing and managing condition like this.

Use of Closed Incision Management with Negative Pressure Therapy for Complex Cardiac Patients.

Background: In patients with major comorbidities undergoing complex cardiothoracic surgery, incision management is critical. This retrospective review evaluated negative pressure over closed sternal incisions in cardiac patients with multiple comorbidities within 30 days post-median sternotomy.Methods: Records of post-sternotomy patients treated with Prevena™ Incision Management System (KCI, an Acelity company, San Antonio, TX), a closed incision negative pressure therapy (ciNPT), were reviewed from September 2010 through September 2014. Data collected included demographics, major comorbidities, types of surgery, relevant medical history, incision length, therapy duration, time to follow-up, and incision complications. Descriptive statistics were computed for continuous variables, frequency, and percentages for categorical variables.Results: Twenty-seven patients were treated with ciNPT between September 2010 and September 2014. The mean patient age was 62.5 (SD 7.9), and the mean body mass index (BMI) was 38.5 (SD 4.4) kg/m2. Risk factors included obesity (BMI ≥ 30 kg/m2, 27/27; 100%), diabetes (25/27; 92.6%), hypertension (16/27; 59.3%), and 20/27 patients (74%) had ≥ 5 comorbidities. Mean ciNPT duration was 5.6 (SD 0.9) days. Within 30 days post-surgery, 21/27 (77.8%) patients had intact incisions with good reapproximation. Two patients experienced minor dehiscences; four cases of superficial cellulitis were treated and resolved. One patient with a dehiscence was readmitted for intravenous antibiotics and five patients were managed successfully with antibiotics as outpatients. All patients had intact incisions with good skin approximation at final follow-up.Conclusions: In this retrospective study of post-sternotomy patients at high risk of developing complications, ciNPT over closed sternal incisions resulted in favorable outcomes within 30 days of surgery.

Sternalock plating system for elderly post-sternotomy patients.

Sternal nonunion after median sternotomy is very stressful for patients and is counted as one of the major postoperative complications reducing quality of life. Conventionally, sternal fixation using metallic wires, sutures, etc., has long been performed. However, postoperative intermittent stress on these fixative materials can cause breakdown of the materials. There are also cases in which the sternum itself rather than the fixative materials is broken. Such events can lead to mediastinal hematoma, necessitating a second thoracotomy or resulting in nonunion in some joints or sternal osteomyelitis [1]. Possible risk factors for sternal nonunion include severe obesity, insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, steroid therapy, coronary artery bypass grafting with the bilateral internal thoracic arteries, and the necessity of loading body weight onto the arms at the time of standing up or walking. Recently, the Sternalock plating system was developed for use in such cases, and favorable clinical outcomes have increasingly been reported primarily from Western countries [2]. This system is composed of a titanium plate (for crosslinking between the right and left stumps of the sternum) and screws for fixation of the plate onto the sternum. Six plate shapes are available, and the screws come in 7 sizes (8–20 mm) to accommodate different sternal thicknesses. In 2013, reimbursement from the insurer for use of the Sternalock plating system was started in Japan, allowing treatment with this system under the national health insurance scheme of this country. This system is currently used for patients at high risk for sternal nonunion. For patients with a fragile sternum due to aging, many surgeons still use wires or other materials for sternal closure (the conventional method). Because of postoperative sternal nonunion in elderly patients has a risk for severe worsening during postoperative course, many surgeons still employed the familiar conventional method. Moreover, as demerits of the Sternalock plating system usage, there are the higher costs and the requirement of the special tool for emergent re-open chest. The present study was undertaken to retrospectively review patients in whom the Sternalock plating system had been used and to examine whether or not this system can be safely and effectively employed in elderly patients. Of the patients who underwent surgery on the heart or large thoracic vessels via a median sternotomy at the Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital between December 2012 and March 2014, 60 seemingly at high risk for sternal nonunion, satisfying at least one of the following requirements, were enrolled in this study: (1) severe obesity (body mass index C130), (2) insulin-dependent diabetes mellitus, (3) chronic obstructive pulmonary disease, (4) having undergone coronary artery bypass grafting employing the bilateral internal thoracic arteries, (5) requirement for loading body weight onto the arms at the time of standing up or walking, (6) receiving hemodialysis, (7) having undergone a second thoracotomy, and (8) taking steroids or other immunosuppressant agents. For the 30 patients who had undergone surgery before September 2013 when the Sternalock plating system was introduced, sternum fixation was achieved T. Nishimura (&) C. Kurihara Y. Sakano S. Kyo (&) Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital, 35-2, Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan e-mail: takashin-tky@umin.ac.jp

Modified chest wall reconstruction after sternum necrosis in cardiac surgery patients

Objective: Complete or partial sternal bone necrosis in poststernotomy patients leads to prolonged hospitalization, distress, reduced quality of life and if untreated to a high mortality. Our proposed treatment of this complication comprises a chest wall reconstruction with metal plates and wires combined with musculocutaneous flap wound closure.

Prevention of sternal dehiscence with the Sternum External Fixation (Stern-E-Fix) corset – a randomized trial in 750 patients

BackgroundThe main objective of this study will be to determine the effects of a new advanced sternum external fixation (Stern-E-Fix) corset on prevention of sternal instability and mediastinitis in high-risk patients.MethodsThis prospective, randomized study (January 2009 – June 2011) comprised 750 male patients undergoing standard median sternotomy for cardiac procedures (78% CABG). Patients were divided in two randomized groups (A, n = 380: received a Stern-E-Fix corset postoperatively for 6 weeks and B, n = 370: control group received a standard elastic thorax bandage). In both groups, risk factors for sternal dehiscence and preoperative preparations were similar.ResultsWound infections occurred in n = 13 (3.42%) pts. in group A vs. n = 35 (9.46%) in group B. In group A, only 1 patient presented with sternal dehiscence vs. 22 pts. in group B. In all 22 patients, sternal rewiring followed by antibiotic therapy was needed. Mediastinitis related mortality was none in A versus two in B. Treatment failure in group B was more than five times higher than in A (p = 0.01); the mean length of stay in hospital was 12.5 ± 7.4 days (A) versus 18 ± 15.1 days (B) (p=0.002). Re-operation for sternal infection was 4 times higher in group B. Mean ventilation time was relatively longer in B (2.5 vs. 1.28 days) (p = 0.01). The mean follow-up period was 8 weeks (range 6 – 12 weeks).ConclusionsWe demonstrated that using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence and secondary sternal infection in high-risk poststernotomy patients.

Primary Sternal Osteomyelitis with Bacteremia and Distal Seeding

BackgroundPrimary sternal osteomyelitis is a rare disease, whereas secondary sternal osteomyelitis is relatively well known as a complication in post-sternotomy patients. ObjectiveDescribe a case of primary Staphylococcus aureus sternal osteomyelitis in an immunocompetent man and its diagnostic challenges, treatment, and complications. Case ReportA 46-year-old man presented with prolonged sternal pain and swelling, fatigue, and fever. He is diagnosed with primary sternal osteomyelitis with concurrent bacteremia and complicated by local and distant abscess formation. The diagnosis was aided by computed tomography, and treatment consisted of incision and drainage and long-term antibiotics. ConclusionPrimary sternal osteomyelitis is uncommon and often difficult to diagnose. Complications include abscess formation and distal seeding. Diagnosis can be aided by a detailed history and radiography, and treatment may consist of a prolonged course of antibiotics and incision and drainage.

Myofascial pain at post-sternotomy patients after cardiac surgery: A clinical study in 1226 patients

Background and objective: Sternotomy is a major type of surgery, and incidence, characteristics and clinical course of post-sternotomy pain are not well known. Myofascial pain also can occur according to sternotomy. So, the aim of this study was to investigate the incidence of myofascial pain and causative factors at post-sternotomy patients in different kind of cardiac surgeries. Methods: This study was performed between the years 2006-2007 at the Department of Cardiothoracic Surgery in Istanbul Kartal Kosuyolu Yuksek Ihtisas Hospital. 1226 patients over 18 years old were evaluated for myofascial pain. Trigger points in both upper trapezius, and both pectoralis major were identified according to Simons and Gerwin diagnostic criteria (tenderness in a hyper sensible spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation). Myofascial pain evaluation again was performed with the same pain physician at all examination periods. Results: When results were evaluated statistically, of the 1226 total patients, only in 194 (15.8%) patients trigger points were determined. When patients who were determined to have trigger points, it was observed that 135 had undergone CABG. These 135 patients were evaluated in 2 groups; those LIMA used and those where LIMA not used. In 102 patients who underwent CABG where LIMA were used (n = 102, 75.5%). Especially of those 194 patients majority suffered from the muscle groups in the left side more than in right side in terms of trigger point formation. Besides that we have determined a parallel relation between the operation duration and trigger point formation that was statistically significant. Conclusion: As a conclusion, the formation of trigger point in upper trapezius and pectoralis major muscles in patients going under CABG with LIMA is 31.9% in patients postoperatively. We believe the reason for this incident is the graft harvesting of the internal mammary artery. Besides we believe that there is a parallel relation between the operation duration and trigger point formation, and more prospective studies are needed to state the relation between the formation of trigger points and the duration of the CABG.