Risk Of Sternal Wound Complications Research Articles

Influence of diabetes and obesity on ten-year outcomes after coronary artery bypass grafting in the arterial revascularisation trial.

Diabetes and obesity are common conditions which can influence outcomes after coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate the influence of diabetes and obesity, and their interactions, on ten-year outcomes following CABG. Patients enrolled in the Arterial Revascularisation Trial (ART) were stratified by diabetes and obesity at baseline. Diabetes was further stratified into insulin and non-insulin dependent. The primary outcome was all-cause mortality at 10years of follow-up. Secondary outcomes were the composite of all-cause mortality, myocardial infarction or stroke at 10years, and sternal wound complications at 6months follow-up. A total of 3096 patients were included in the analysis (24% with diabetes, 30% with obesity). Patients in the "diabetes/no obesity" group had a higher risk of all-cause mortality following CABG (adjusted hazard ratio [aHR] 1.33, 95% confidence interval [CI] 1.08-1.64, p = 0.01) compared to the reference group of "no diabetes/no obesity". No excess risk was observed in the "no diabetes/obesity" or "diabetes/obesity" groups. Patients with insulin dependent diabetes had a significantly higher ten-year mortality risk compared to no diabetes (aHR 1.85, 95% CI 1.41-2.44, p = 0.00). Patients in the "diabetes/no obesity" and "diabetes/obesity groups" had a higher risk of sternal wound complications (HR 2.29, 95% CI 1.39-3.79, p < 0.001 and HR 3.21, 95% CI 1.89-5.45, p < 0.001 respectively). The composite outcome results were consistent with the mortality results. Diabetes, especially insulin dependent diabetes, is associated with a higher ten-year mortality risk after CABG, in contrast to obesity which does not appear to increase long term mortality compared to non-obese. The interaction between diabetes and obesity shows an apparent "protective" effect of obesity irrespective of diabetes on mortality. Both conditions are associated with a higher risk of post-operative sternal wound infections.

Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A "Work in Progress" Analysis.

Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p < 0.001). Diabetes mellitus (O.R. 3.5; p < 0.001) and COPD (O.R. 21.3; p < 0.001) were independent predictors for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p < 0.001) with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p < 0.001). No other radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion. PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound complications, allowing for early preventative measures.

Outcomes after coronary artery bypass graft surgery: systematic review and meta-analysis comparing bilateral versus single internal thoracic artery grafts

Abstract Background Patients with diabetes and/or obesity are at higher risk of adverse outcomes following coronary artery bypass grafting (CABG). The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA) in patients undergoing CABG, but the overall evidence base for BITA has not influenced guidelines, and there are concerns over increased risk of sternal wound complications. Methods We conducted a systematic review of the literature to identify observational studies and randomised controlled trials (RCT) comparing the efficacy (mortality) and safety (sternal wound infection) of BITA and SITA in diabetic and obese patients. Results We identified 18 observational studies and one RCT to obtain data comparing BITA and SITA in 19,589 diabetic patients, and two observational studies and one RCT comparing BITA and SITA in 6972 obese patients. Pooled analysis demonstrated significant mortality benefit of BITA compared to SITA in diabetic patients (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70, 0.90; Z=3.62, p=0.0003; I2=88%) (Figure 1a). Pooled analysis in obese patients found no significant difference in mortality rates between BITA and SITA (RR 0.73, 95% CI 0.47, 1.12; Z=1.43, p=0.15; I2=78%) (Figure 1b). A significantly higher rate of sternal wound complications following BITA was observed in diabetic (RR 1.53, 95% CI 1.23, 1.90; Z=3.86, p=0.0001; I2=4%) and obese patients (RR 2.24, 95% CI 1.63, 3.07; Z=5.00, p&amp;lt;0.00001; I2=0%). Conclusions BITA is associated with better long-term survival in diabetic patients, but most of the supportive data comes from observational studies. The effects of BITA grafting in patients who are obese is uncertain due to low numbers. BITA is associated with higher rates of sternal wound complications than SITA in both diabetic and obese patients. Further research is needed to understand if BITA has a role in higher risk patients undergoing CABG. Figure 1. Pooled all-cause mortality Funding Acknowledgement Type of funding source: None

Multiple versus single arterial grafting in coronary artery bypass grafting: A meta-analysis of randomized controlled trials and propensity score studies

ObjectivesWe conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and major adverse cardiac and cerebrovascular events (MACCEs) of patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG). MethodsMEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960–2018). Survival at a follow-up ≥1 year, MACCEs and early outcomes were evaluated. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance, and the other endpoints using frequencies from matched sample or adjusted odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events). ResultsTwenty-nine PS cohorts and 8 RCTs comprising 122,832 patients (52,178 MAG and 70,654 SAG) were included in this meta-analysis. MAG was associated with lower early mortality (OR: 0.82, 95%CI: 0.71–0.95, p = .007), long-term mortality (HR: 0.76, 95%CI: 0.73–0.78, p < .001) and MACCEs (HR: 0.85, 95%CI: 0.79–0.91, p < .001). Increased risk of sternal wound complications (SWC) was only observed when the bilateral internal mammary artery configuration was used for MAG (OR MAG BIMA: 1.96, 95%CI: 1.37–2.81, p < .001). ConclusionAlthough the BIMA configuration increases the risk of SWC, MAG improves both early and long-term survival as well as MACCEs in CABG.

Invited Commentary

Advanced hybrid coronary revascularization (AHCR) marries the long-term patency and survival benefits of multiple internal mammary arterial grafts to the effectiveness of drug-eluting stents for residual stenoses among patients with complex left main and 3-vessel coronary artery disease. This technique affords patients a sternal-sparing approach, potentially allowing patients an earlier return to full activity while avoiding the risk of sternal wound complications associated with standard coronary artery bypass grafting (CABG). In this issue of The Annals of Thoracic Surgery, Balkhy and colleagues1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar report outcomes from their series of AHCR using multiple internal mammary arterial grafts and second-generation drug-eluting stents. Patients were evaluated by an experienced heart team that calculated baseline and residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores. Compared with open surgical revascularization, operative times were prolonged, but the authors should be congratulated for excellent early outcomes with no 30-day mortality, surgical site infection, perioperative stroke, or reexploration for bleeding. Another strength of the current study was the routine use of follow-up angiography, leading to a more comprehensive assessment of the completeness of revascularization. Incomplete revascularization has been more rigorously defined by the residual SYNTAX score (rSS). A key finding by Balkhy and associates1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar is that patients with increased rSSs (suggesting incomplete revascularization) were associated with higher mortality and major adverse cardiac events, which indicates the importance of complete revascularization to optimize clinical results in complex coronary artery disease. As the authors noted, however, it is difficult to elucidate whether these outcomes arise directly from incomplete revascularization, as this group did have greater comorbidities and the sample size was too small to allow for adjustments. Inferior outcomes have been associated with incomplete revascularization in previous studies of percutaneous coronary intervention, and standard CABG and hybrid coronary revascularization, particularly in patients on renal dialysis. When heart teams consider AHCR options, the concept of a “predictive rSS” for all possible revascularization options may guide the optimal treatment strategy. Each lesion should be assessed regarding the feasibility of both percutaneous coronary intervention and CABG and hypothetical rSSs, presuming the failure of various revascularization strategies could be calculated. In this fashion, heart teams could assess revascularization options based on predictive “worst case” scenarios and their presumed likelihood, providing insight into the potential best strategy. To date, only one randomized controlled trial has been conducted.2Gąsior M. Zembala M.O. Tajstra M. et al.Hybrid revascularization for multivessel coronary artery disease.JACC Cardiovasc Interv. 2014; 7: 1277-1283Crossref PubMed Scopus (89) Google Scholar Although underpowered for long-term outcomes and lacking protocol-driven angiographic follow-up, reduced perioperative complications were demonstrated with an increased risk of long-term revascularization. Inclusion of large observational studies in meta-analyses has also demonstrated similar results.3Nolan S. Filion K.B. Atallah R. Moss E. Reynier P. Eisenberg M.J. Hybrid coronary revascularization vs. complete coronary artery bypass grafting for multivessel coronary artery disease: a systematic review and meta-analysis.J Invasive Cardiol. 2018; 30: E131-E149PubMed Google Scholar The effectiveness of AHCR can only be ascertained through a multicenter prospective randomized controlled trial of complex revascularization comparing standard CABG with AHCR. Ideally, this study would assess the differences in initial surgical complications along with long-term major adverse cardiac events and revascularization rates and include a cohort of protocol-driven angiographic follow-up to ascertain the mode of revascularization failure. The future for AHCR remains bright, but will rely heavily on experienced heart teams. With persistence in continued training, the development of simplified robotic techniques, and appropriate funding for dedicated prospective clinical trials to determine which patient subsets benefit most, AHCR may ultimately be proven to be the best approach for many patients to improve outcomes and minimize complications. Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary RevascularizationThe Annals of Thoracic SurgeryVol. 109Issue 6PreviewAdvanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score. Full-Text PDF

Bilateral internal thoracic artery versus single internal thoracic artery: a meta-analysis of propensity score-matched observational studies.

The lack of benefit in terms of mid-term survival and the increase in the risk of sternal wound complications published in a recent randomized controlled trial have raised concerns about the use of bilateral internal thoracic artery (BITA) in myocardial revascularization surgery. For this reason, we decided to explore the current evidence available on the subject by carrying out a meta-analysis of propensity score-matched studies comparing BITA versus single internal thoracic artery (SITA). PubMed, EMBASE and Google Scholar were searched for propensity score-matched studies comparing BITA versus SITA. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The DerSimonian and Laird method was used to compute the combined risk ratio of 30-day mortality, deep sternal wound infection and reoperation for bleeding. Forty-five BITA versus SITA matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival in favour of the BITA group [HR 0.78; 95% confidence interval (CI) 0.71-0.86]. These results were consistent with those obtained by a pooled analysis of the matched populations comprising patients with diabetes (HR 0.65; 95% CI 0.43-0.99). When compared with the use of SITA plus radial artery, BITA did not show any significant benefit in terms of long-term survival (HR 0.86; 95% CI 0.69-1.07). No differences between BITA and SITA groups were detected in terms of 30-day mortality or in terms of reoperation for bleeding. Compared with the SITA group, patients in the BITA group had a significantly higher risk of deep sternal wound infection (risk ratio 1.66; 95% CI 1.41-1.95) even when the pooled analysis was limited to matched populations in which BITA was harvested according to the skeletonization technique (risk ratio 1.37; 95% CI 1.04-1.79). The use of BITA provided a long-term survival benefit compared with the use of SITA at the expense of a higher risk of sternal deep wound infection. The long-term survival advantage of BITA is undetectable when compared with SITA plus radial artery.

Robotically Assisted Minimally Invasive Off-Pump Coronary Artery Bypass Surgery in a Patient With Permanent Tracheostomy

Patients with a permanent tracheostomy requiring coronary surgery represent a unique challenge, being at increased risk of sternal wound complications, mediastinitis and stoma necrosis. Several techniques have been described including manubrium sparing sternotomy, thoracoscopic internal mammary harvest and hybrid revascularisation. We report a case of robotic assisted (daVinci®Xi™ Surgical System) total arterial off-pump revascularisation in a patient with previous laryngectomy and permanent tracheostomy. The main advantage of this approach was to minimise the risk of postoperative sternal complication and mediastinatis, whilst still providing the prognostic benefit of total arterial grafting and the neurological advantage of the aorta no-touch technique.

14-Year Results of Bilateral versus Single Internal Thoracic Artery Grafts for Left-Sided Myocardial Revascularization in Young Diabetic Patients.

Objectives Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal wound complications. In the present study, early- and long-term outcomes of the use of left-sided BITA versus single internal thoracic artery (SITA) grafting in young (< 65 years of age) diabetic patients were reviewed retrospectively. Methods A total of 250 propensity score pair-matched diabetic patients, operated on between February 2000 and December 2011, receiving either BITA (n = 125) or SITA (n = 125) grafting were analyzed retrospectively. In each group, 104 patients were males, and mean age was 60.1 ± 5.3 years. Follow-up was 2.1 to 14.8 years (mean, 9.3 ± 3.5 years) and complete for 100%. Results Incidence of deep sternal wound infection was 2.4 versus 3.2% (p = 0.722). Rethoracotomy due to bleeding occurred in 4.8 versus 3.2% (p = 0.608). The 5-, 10-, and 14-year estimates of survival were 93.4, 76.6, and 67.5% (BITA) versus 89.5, 81.5, and 32.8% (SITA); p = 0.288. Freedom from reangiography/intervention (60.5 vs. 63.9%) during follow-up was comparable (p = 0.507) as well as infarction rate (93.8 vs. 95.1%, p = 0.833) and redoes (p = 0.672, exclusively valve surgery) were comparable. Freedom from thromboembolic or cerebrovascular events did not show any significant differences (94.0 vs. 94.0%, p = 0.78). Multivariate analysis identified poor ejection fraction as predictor for decreased long-term survival. Neither age nor gender or urgency had an influence on long-term mortality. Conclusion Left-sided BITA grafting may be performed routinely even in diabetic patients without increased incidence of postoperative wound-healing complications. Survival rates after 5, 10, and 14 years were comparable for BITA and SITA grafting.

Risk factors of infected sternal wounds versus sterile wound dehiscence

BackgroundSterile sternal dehiscence (SSD) and sternal wound infections (SWIs) are two complications of median sternotomy with high rates of morbidity. Sternal wound complications also carry significant economic burden, almost tripling patients' hospital costs and are considered a nonreimbursable “never event” for Medicare. Historically, SDD and SWI have been recognized as discrete entities, but nonetheless continue to be categorized as a singular complication in literature. The purpose of this study was to determine specific patient demographic and perioperative predictors of SSD and SWI. Materials and methodsAn institutional review board–approved, retrospective study of 8098 consecutive patients who underwent cardiac surgery at Columbia University Medical Center between January 2008 and December 2013 was conducted. Patients were categorized into three groups: no sternal wound complication, SSD, or SWI. Statistical analysis was performed using univariate and multivariate logistic regression analysis. ResultsOf 8098 patients, there were 73 patients (0.9%) with SSD and 40 (0.5%) with SWI who required plastic surgical consultation, debridement, and flap closure. In univariate analysis of SSD, positive predictors (i.e., “risk” factors) were age >42 years, prior surgery this admission, ≥2 arterial conduits, internal mammary artery (IMA) grafting with or without previous IMA grafting, body mass index (BMI) >30 (obese), CHF, diabetes requiring medication, respiratory failure, and unplanned cardiac reoperation; negative predictors (i.e., “protective” factors) were no arterial conduits and extubation within 24 h. In univariate analysis of SWI, positive predictors were IMA grafting with or without previous IMA grafting, postoperative hematocrit urgent/emergent surgical priority, BMI >30 (obese), cardiac ejection fraction <40%, and respiratory failure; negative predictors were no arterial conduits and elective surgical priority. In multivariate regression, BMI >30, diabetes requiring medication, and respiratory failure were determined to be significant positive predictors of SSD, and IMA grafting with or without prior IMA grafting and respiratory failure were significant positive predictors for SWI; no significant negative predictors were identified. ConclusionsThis study found that SSD and SWI have many common significant predictors consistent with findings that increased BMI, use of IMA grafts, poor cardiac reserve, and postoperative respiratory failure confer increased risk of sternal wound complications. Additionally, this study also found that there were predictors unique to each entity supporting that SSD and SWI may be related but are not a singular entity. Recognition and prevention of significant positive and negative predictors of SSD and SWI may be valuable in preoperative counseling, operative planning, and postoperative management. Although sternal wound complications can be successfully managed by plastic surgical intervention, preventing the development of median sternotomy complications may curb costs incurred by both patients and health care systems.

Long-term results of multiple arterial bypass conduits.

Ongoing efforts to compare percutaneous coronary intervention with coronary bypass surgery for multivessel coronary disease mandate that surgeons reevaluate best practices for coronary surgery in order to maximize long-term outcomes. This review presents recent data for the long-term outcomes of multiple arterial grafting in terms of patient selection, conduit choice, and technical considerations. Multiple arterial grafting remains poorly utilized, with fewer than 10% of cases receiving more than one arterial graft. Bilateral internal thoracic artery grafting confers superior long-term survival and freedom from reoperation over single thoracic artery with saphenous vein. Use of a second internal thoracic artery graft is advantageous in diabetic patients despite higher risk of sternal wound complications. Routine use of skeletonized grafts and Y or T grafting to allow complete revascularization allows lower early complication rates and better long-term survival. Radial artery grafts confer superior long-term survival compared with saphenous vein grafts and should be considered in patients at high risk for sternal wound complications. Multiple arterial grafting confers superior long-term outcomes in comparison with single internal thoracic artery grafting and should be considered as the standard of care.

Bilateral internal thoracic artery use: will another retrospective study ever strengthen the prospect?

Since the introduction of coronary artery bypass grafting (CABG) 50 years ago [1], the conduit choice to bypass coronary artery stenosis continues to be a debate [2]. Already in the early years, CABG was performed using internal thoracic arteries (ITAs). However, it took several decades before evidence supported the use of ITAs, when Loop et al. showed that the left ITA (LITA) to the left anterior descending (LAD) artery prolonged long-term survival when compared with a saphenous vein graft [3]. Several research groups went even further by claiming that bilateral ITA (BITA) grafting was superior to the use of a single ITA (SITA). Although these initial studies were merely retrospective, the use of the LITA to the LAD became widely accepted with >90% of patients receiving this construction in contemporary CABG practice [4]. The fate of BITA grafting has been less fortunate. Over the past 25 years, a staggering number of retrospective and prospective observational studies have published long-term results of BITA versus SITA use. The majority of studies concluded that BITA grafting either reduced mortality or showed to have comparable results with SITA grafting. In a recent meta-analysis that exclusively included studies with long-term follow-up of at least a mean of 9 years (n = 9 studies comprising 15 583 patients with nearly 200 000 patient-years of follow-up), BITA versus SITA grafting significantly reduced mortality with a hazard ratio of 0.79, 95% confidence interval (CI) 0.75–0.84 [5]. Despite these encouraging results, BITA use remains remarkably low. Among patients who underwent CABG in the SYNTAX trial and registry, BITA grafting was performed in 10% in the USA and 25% in Europe [6]. Another ‘real-world’ analysis of 541 368 patients receiving CABG in the USA showed that the rate of BITA use increased over consecutive years but remained low during the entire study period: 3.6% in 2002 to 4.5% in 2005 [7]. The reason for the disappointing adoption of BITA use is multifactorial. The choice to use both ITA conduits depends strongly on the motivation of the surgeon. Surgeons in favour of BITA grafting cite evidence of observational studies that reported improved long-term survival, while those surgeons not particularly in favour of BITA grafting refer to the fact that there is currently no randomized clinical trial with long enough follow-up to confirm that BITA is indeed better than SITA. Moreover, surgeons may be reticent to using both ITA grafts because of the higher complexity of the procedure and the increased risk of sternal wound complications found particularly in diabetic, obese women. Besides patient characteristics like diabetes, body mass index and gender, age is a decisive factor [7], as the benefit of BITA over SITA only occurs after prolonged follow-up. A life expectancy of at least 10 years appears to be needed to show significant benefit of BITA use. In this regard, the current issue of the European Journal of CardioThoracic Surgery includes a retrospective study from Pettinari et al. in which they performed a propensity-matched analysis comparing BITA with SITA in elderly patients >70 years of age, to assess whether the benefit of BITA grafting can be extended to elderly patients [8]. The authors showed that patients who underwent BITA grafting, when compared with patients who received only a SITA, were younger, and less often had peripheral vascular disease, diabetes, chronic obstructive pulmonary disease or a recent myocardial infarction, all factors known to be associated with impaired survival during follow-up. The authors therefore were correct in performing a propensity-matched analysis after which no differences in the BITA and SITA groups existed. In terms of outcomes, BITA grafting showed to have superior survival after 3 months, 1 year and 10 years in the unmatched groups. After matching and as anticipated due to the differences in baseline characteristics, the difference between BITA and SITA was smaller, with BITA grafting only being superior after 10 years of follow-up (multivariate hazard ratio of 0.78, 95% CI 0.64–0.96; P = 0.04) [8]. The authors have to be congratulated for achieving such good results with BITA grafting. However, several significant limitations of the current study should be acknowledged, putting these results in the correct perspective. Of the 1328 and 2168 patients who underwent BITA and SITA grafting, respectively, only 892 propensity-matched pairs could be achieved. The fact that two-thirds of patients could not be matched indicates that these groups were significantly different. Although there were no longer any significant differences between the groups after matching, the authors were unable to match patients on the refinement of the surgical technique; the inclusion was during 1972–2006, with BITA being performed in the later decades, during which the CABG procedure changed considerably with improved outcomes. Furthermore, clinical variables as well as clinical judgement, which

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: A case-control study of 1526 patients

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001–2013) was conducted to investigate the impact of the two strategies on early and late outcomes. Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2–3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0–2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1–9.7) and obese patients (HR 2.1; 95% CI 0.8–5.46). Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

Is There a Role for Robotic Totally Endoscopic Coronary Artery Bypass in Patients With a Colostomy?

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

EComment. Prevention of sternal wound infection

We read with great interest the article by Sakic et al. [1] assessing the efficacy of surgical modifications on the incidence of postoperative sternal complications after bilateral internal thoracic arteries (BITA) harvesting. In this single-center retrospective study, the authors demonstrated that using a skeletonized approach in patients receiving bilateral internal thoracic arteries with augmented sternal wires is effective in preventing sternal wound complications. As described by others, this series supports the claim that the risk of sternal infection can be reduced by performing internal thoracic artery harvested in a skeletonized manner. Deo et al. [2] conducted the first systematic review and meta-analysis to address the essential clinical question of whether BITA increases the risk of deep sternal wound infection in patients with diabetes; they concluded that the risk may be minimized using a skeletonized approach. The left internal thoracic artery to left anterior descending artery graft has long been established as the cornerstone of improved early and late outcomes in surgically-treated patients. An overwhelming wealth of evidence, mainly retrospective studies, demonstrated that the use of BITA as bypass grafts provided superior early survival and better event-free survival after coronary artery bypass grafting. The Arterial Revascularization Trial [3] is the only randomized study comparing the outcomes of single internal mammary artery (SITA) vs BITA, with a primary outcome of survival at 10 years, and results should be available in five years. The risk of sternal wound complications may need to be weighed against the long-term benefit of BITA grafts. It is, needless to say, that anterior mediastinitis is a rare but ominous complication after BITA harvesting, carrying a high risk of in-hospital mortality. Many factors have been suggested as responsible for postcardiotomy sternal wound infection, and investigations to prevent this dreaded complication are still considered as a greatly researched topic in cardiac surgery. Recently, Grauhan et al. [4] investigated the efficacy of a new commercially available negative pressure wound therapy system (Prevena Incision Management System; KCI, San Antonio, USA) as a dressing treatment to prevent sternal wound infection in obese patients undergoing cardiac surgery. They showed in a prospective study that the application of a special foam as a wound dressing immediately after skin closure and negative pressure of -125 mmHg for the first 6 to 7 days postoperatively significantly reduces the incidence of sternal infection in this high-risk patient population. The technique of skeletonization during BITA harvest preserves sternal microacirculation [5]; the immediate application of a negative-pressure wound dressing after suturing prevents the breakdown of skin sutures and seepage of bacteria into the deeper layers. These two different methods showed to be effective in reducing the likelihood of sternal wound infection, and should be considered in high-risk patients of sternal complications. Conflict of interest: none declared.

Simple adaptations of surgical technique to critically reduce the risk of postoperative sternal complications in patients receiving bilateral internal thoracic arteries

Limited blood supply to the thoracic chest wall is a known risk factor for sternal wound complications after CABG. Therefore, bilateral internal thoracic arteries are still rarely utilized despite their proven superior graft patency. The aim of our study was to analyse whether modification of the surgical technique is able to limit the risk of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. All 418 non-emergent CABG patients receiving bilateral internal thoracic artery CABG procedures (BITA) from January 2001 to January 2012 were analysed for sternal wound complications. Surgical technique together with known risk factors and relevant comorbidity were analysed for their effect on the occurrence of sternal wound complications by means of multivariate logistic regression analysis. Sternal wound complications occurred in 25 patients (5.9%), with a sternal dehiscence rate of 2.4% (10 patients). In multivariate analysis, diabetes (odds ratio [OR]: 4.8, 95% CI: 1.9-11.7, P=0.001), but not obesity (OR: 1.6, 95% CI: 0.7-4.2, P=0.28) or chronic obstructive pulmonary disease (OR: 2.2, 95% CI: 0.87-5.6, P=0.1) was a relevant comorbid condition for sternal complications. Skeletonization of ITA grafts (OR: 0.17, 95% CI: 0.06-0.5, P=0.001) and the augmented use of sternal wires (OR: 0.24, 95% CI: 0.06-0.95, P=0.04) were highly effective in preventing sternal complications. The use of platelet-enriched-fibrin glue (PRF) sealant, however, was associated with more superficial sternal infections (OR: 3.7, 95% CI: 1.3-10.5, P=0.02). Adjusted for common risk factors, skeletonization of BITA grafts together with augmented sternal wires is effective in preventing sternal complications. The use of PRF sealant, however, increased the risk for superficial wound complications.

In-Hospital Outcomes of Pedicled Bilateral Internal Mammary Artery Use in Diabetic and Nondiabetic Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: Single-Surgeon, Single-Center Experience

A common perception is that use of pedicled bilateral internal mammary arteries (BIMA) increases the risk of sternal wound complications in diabetic patients undergoing coronary artery bypass grafting (CABG). The purpose of this study was to compare the in-hospital outcomes of CABG using pedicled BIMA in diabetic and nondiabetic patients. From September 1998 to September 2010, 390 consecutive diabetic patients and 519 nondiabetic patients underwent isolated off-pump CABG using pedicled BIMA. The 2 groups had comparable preoperative demographics except for a higher prevalence of acute myocardial infarction (18.9% versus 6.1%, P = .01), peripheral vascular disease (17.2% versus 2.7%, P = .001), an ejection fraction <30% (17.7% versus 8.5%, P = .02), and chronic renal failure (4.5% versus 0.9%, P = .01) in the diabetic patients. The operative mortality rate of the diabetic patients was comparable to that of the nondiabetic patients (2.8% versus 2.1%, P = .87). The in-hospital outcomes, including occurrence of superficial and deep sternal wound infections, were similar except for an increased occurrence of wound infection at the vein harvest site (6.6% versus 1.1%, P = .04) and a need for hemofiltration (11.8% versus 2.1%, P = .02) in the diabetic patients. Pedicled BIMA use is associated with comparable incidences of sternal wound complications and other outcomes in diabetic patients and nondiabetic patients. Strict perioperative glycemic control, adherence to meticulous closure technique, and postoperative management of surgical wounds can make pedicled BIMA use a default strategy for diabetic patients.

Coronary Revascularization Using Bilateral Internal Thoracic Arteries: Safe with Skeletonization?

Substantial evidence exists to support a long-term survival benefit with bilateral internal thoracic artery (BITA) revascularization in coronary artery bypass grafting. However, this technique remains grossly underutilized worldwide and especially in the United States. In this review, we discuss evidence for the advantages of BITA grafting as well as the associated the risk of sternal wound complications. We then review a growing body of literature that suggests ‘skeletonization’ of the internal thoracic artery during harvest confers a protective benefit against sternal wound infection in patients receiving BITA.

Sternal Closure With Rigid Plate Fixation Versus Wire Closure: A Randomized Controlled Multicenter Trial

Rigid bone fixation is the standard of care for all bone reconstructions except that after sternotomy. Sternal reconstruction after median sternotomy using rigid fixation with plates may improve bone healing and reduce pain when compared with wire cerclage. One-hundred forty patients at six centers who were determined preoperatively to be at high risk for sternal wound complications were randomly assigned to sternal closure with rigid plate fixation (n=70) or wire cerclage (n=70). Sternal healing was evaluated at 3 or 6 months by a core laboratory using computed tomography. Pain and function were evaluated at postoperative day 3 through discharge, 3 weeks, 6 weeks, 3 months, and 6 months. Sternal healing was superior in rigid plate fixation patients at both 3 and 6 months. Mean computed tomography scores in the rigid plate fixation and wire cerclage groups at 3 months were 1.7±1.1 and 0.9±0.8 (p=0.003). At 6 months, the scores were 3.2±1.6 and 2.2±1.1, respectively (p=0.01). At 6 months, 70% of rigid plate fixation patients had achieved sternal union, compared with 24% of conventional wire cerclage patients (p=0.003). Pain scores and narcotic usage were lower in rigid plate fixation patients. Significant differences in pain scores were observed at 3 weeks for total pain (p=0.020) and pain with coughing (p=0.0084) or sneezing (p=0.030). Complication rates were similar in both groups. Sternal reconstruction using rigid fixation with plates improved bone healing and reduced early postoperative pain compared with wire cerclage.

Indications and Risks of Delayed Sternal Closure After Open Heart Surgery in Neonates and Early Infants

Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years. The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days). Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively (P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group (P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively). Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.

Pilot Study of Sternal Plating for Primary Closure of the Sternum in Cardiac Surgical Patients

Postoperative sternal wound complications are a significant problem in high-risk patients. In addition to closure with conventional wires, several systems involving rigid fixation with metal plates are currently available. The rapid sternal closure system (Talon) is approved for stabilization and fixation of the anterior chest wall. Anecdotal evidence suggests that use of the Talon may result in improved postoperative recovery. Fifty-one cardiac surgical patients at higher risk for sternal wound complications were enrolled at two sites. Subjects were randomized to insertion of Talons (n = 28) or wires only (control, n = 23) for sternal closure. The primary endpoint was a comparison between study groups of the percent of baseline incentive spirometry volume through postoperative day 7. Secondary endpoints included other measures of quality of recovery, sternal wound infection, and nonunion. The percentage of preoperative incentive spirometry volume achieved was higher in the Talon arm (67% ± 32%) versus control (58% ± 24%); however, this was not statistically significant (P = 0.41). Use of the Talon was associated with decreased use of opiates (21.3 ± 11.8 vs. 25.4 ± 21.6 mg, P = 0.44), increased ability to ambulate 1000 ft on postoperative day 5 (25% vs. 13%, P = 0.28), and decreased duration of mechanical ventilation (median 0.5 vs 1.0 days, P = 0.24) and hospital length of stay (4.5 ± 3.2 vs. 5.3 ± 4.0 days, P = 0.40). One superficial sternal wound infection was observed in each study arm. There were no cases of nonunion. In this pilot study, the primary endpoint was not statistically different between the treatment groups. Use of the Talon was associated with trends toward benefit in endpoints consistent with enhanced postoperative recovery, highlighting a need for additional data from larger randomized trials.