Risk Of Sternal Wound Infection Research Articles

Regional antibiotic delivery for sternal wound infection prophylaxis a systematic review and meta-analysis of randomized controlled trials

Despite evidence suggesting the benefit of prophylactic regional antibiotic delivery (RAD) to sternal edges during cardiac surgery, it is seldom performed in clinical practice. The value of topical vancomycin and gentamicin for sternal wound infections (SWI) prophylaxis was further questioned by recent studies including randomized controlled trials (RCTs). The aim of this systematic review and meta-analysis was to comprehensively assess the safety and effectiveness of RAD to reduce the risk of SWI.We screened multiple databases for RCTs assessing the effectiveness of RAD (vancomycin, gentamicin) in SWI prophylaxis. Random effects meta-analysis was performed. The primary endpoint was any SWI; other wound complications were also analysed. Odds Ratios served as the primary statistical analyses. Trial sequential analysis (TSA) was performed.Thirteen RCTs (N = 7,719 patients) were included. The odds of any SWI were significantly reduced by over 50% with any RAD: OR (95%CIs): 0.49 (0.35–0.68); p < 0.001 and consistently reduced in vancomycin (0.34 [0.18–0.64]; p < 0.001) and gentamicin (0.58 [0.39–0.86]; p = 0.007) groups (psubgroup = 0.15). Similarly, RAD reduced the odds of SWI in diabetic and non-diabetic patients (0.46 [0.32–0.65]; p < 0.001 and 0.60 [0.44–0.83]; p = 0.002 respectively). Cumulative Z-curve passed the TSA-adjusted boundary for SWIs suggesting adequate power has been met and no further trials are needed. RAD significantly reduced deep (0.60 [0.43–0.83]; p = 0.003) and superficial SWIs (0.54 [0.32–0.91]; p = 0.02). No differences were seen in mediastinitis and mortality, however, limited number of studies assessed these endpoints. There was no evidence of systemic toxicity, sternal dehiscence and resistant strains emergence. Both vancomycin and gentamicin reduced the odds of cultures outside their respective serum concentrations’ activity: vancomycin against gram-negative strains: 0.20 (0.01–4.18) and gentamicin against gram-positive strains: 0.42 (0.28–0.62); P < 0.001. Regional antibiotic delivery is safe and effectively reduces the risk of SWI in cardiac surgery patients.

Use of temporary tracheostomy occlusion to reduce the risk of sternal wound infection after sternotomy in congenital cardiac surgery.

To describe a method of reducing the risk of sternal wound infection after sternotomy in children with a pre-existing tracheostomy. To report our outcomes using this method from 1 January, 2013 to 31 August, 2023. We describe a method for temporarily occluding the tracheal stoma with a removable implant with the primary goal of reducing the risk of sternotomy wound infection by preventing soilage due to tracheostomal secretions. We then performed a retrospective review of all children who underwent temporary tracheostomal occlusion between 1 January, 2013 and 31 August, 2023 at our quaternary care children's hospital. Clinical variables were extracted from the hospital medical records. The rates of antibiotic use and minor and major complications during the period when the stoma plug was in place were recorded. Totally, 19 patients underwent tracheal stoma plugging prior to sternotomy and were included in our analysis. There were two cases of sternal wound infection; one case occurred while the stoma plug was in place, and one developed four days following plug removal. There was one minor complication, with one patient requiring stoma revision via serial dilation at bedside at the time of recannulation. There were no deaths. Temporary occlusion of the tracheal stoma with an impermeable plug is a viable option for reducing the risk of sternal wound infection in children with a pre-existing tracheostomy who are undergoing sternotomy.

Topical vancomycin for sternal wound infection prophylaxis. A systematic review and updated meta-analysis of over 40,000 cardiac surgery patients

BackgroundDespite guideline recommendations, routine application of topical antibiotic agents to sternal edges after cardiac surgery is seldom done. Recent randomized controlled trials have also questioned the effectiveness of topical vancomycin in sternal wound infection prophylaxis. MethodsWe screened multiple databases for observational studies and randomized controlled trials assessing the effectiveness of topical vancomycin. Random effects meta-analysis and risk-profile regression were performed, and randomized controlled trials and observational studies were analyzed separately. The primary endpoint was sternal wound infection; other wound complications were also analyzed. Risk ratios served as primary statistics. ResultsTwenty studies (N = 40,871) were included, of which 7 were randomized controlled trials (N = 2,187). The risk of sternal wound infection was significantly reduced by almost 70% in the topical vancomycin group (risk ratios [95% confidence intervals]: 0.31 (0.23–0.43); P < .00001) and was comparable between randomized controlled trials (0.37 [0.21–0.64]; P < .0001) and observational studies (0.30 [0.20–0.45]; P < .00001; Psubgroup = .57). Topical vancomycin significantly reduced the risk of superficial sternal wound infections (0.29 [0.15–0.53]; P < .00001) and deep sternal wound infections (0.29 [0.19–0.44]; P < .00001). A reduction in the risk of mediastinitis and sternal dehiscence risks was also demonstrated. Risk profile meta-regression showed a significant relationship between a higher risk of sternal wound infection and a higher benefit accrued with topical vancomycin (ß-coeff. = −0.00837; P < .0001). The number needed to treat was 58.2. A significant benefit was observed in patients with diabetes mellitus (risk ratios 0.21 [0.11–0.39]; P < .00001). There was no evidence of vancomycin or methicillin resistance; on the contrary, the risk of gram-negative cultures was reduced by over 60% (risk ratios 0.38 [0.22–0.66]; P = .0006). ConclusionTopical vancomycin effectively reduces the risk of sternal wound infection in cardiac surgery patients.

Does bone wax make sense in off-pump coronary surgery? A prospective randomized study.

The effect of bone wax on sternal infection and intraoperative bleeding in off-pump coronary surgery has not been reported in current literature. To prospectively evalute this in a cohort of high risk patients undergoing off-pump coronary artery surgery at our institution. The potential impact on cell saver utilization was also studied. A prospective randomized study was performed in 58 diabetic patients operated on for two-vessel coronary artery disease by the off-pump technique. They were randomly assigned to the wax or no-wax group. There was no significant difference in intraoperative blood loss between the wax (550 ml) and no-wax group (750 ml; p = 0.0711). In multivariate analysis the absence (non-use) of bone wax (odds ratio = 3.9 (1.12-13.51), p = 0.027) and preoperative creatinin level (odds ratio = 1.1 (0.99-1.03), p = 0.03) were identified as independent predictors of blood loss ≥ 750 ml. The number of red blood cell units during hospital stay was similar in both groups (p = 0.42). Wound healing complications were not observed in either group. The use of bone wax does not lead to a higher risk of sternal wound infection. It may reduce the risk of high intraoperative blood loss, thus avoiding the need of a cell saver during off-pump coronary surgery. However, this influence remains questionable.

Topical Vancomycin and Risk of Sternal Wound Infections: A Double-Blind Randomized Controlled Trial

BackgroundThe use of topical vancomycin in the reduction of sternal wound infection (SWI) risk has become a point of contention. The earlier literature consists of observational studies and 1 unblinded trial. Hence, the objective of this study was to assess whether vancomycin reduces the incidence of SWI in a double-blind randomized controlled trial. MethodsPatients were randomized 1:1 to either vancomycin-soaked (vancomycin) or saline-soaked (control) sponges. The sponges were applied once the sternum was opened and were removed just before sternal closure. Patients were followed up at 3 months and at 1 year postoperatively to determine the incidence of SWI in each group. Results were analyzed according to the modified intention-to-treat principle. ResultsThis study assessed 1038 patients for eligibility and enrolled 1037 patients. There were 517 patients randomized to the vancomycin group and 520 patients randomized to the control group. Analysis was performed on 1021 patients. At 3 months postoperatively, there was no significant difference in the incidence of SWI between the vancomycin and control groups (2.7% vs 4.1%; P = .23). There was also no significant difference between the vancomycin and control groups in the risk of superficial, deep, and organ-space infections. Similar findings were observed 1 year postoperatively. The most common organism isolated was coagulase-negative Staphylococcus. ConclusionsThe use of vancomycin applied to the sternum during cardiac surgery does not reduce the incidence of SWI.

177 Pedicled Or Skeletonized Bilateral Internal Mammary Artery Harvesting - A Meta- Analysis and Trial Sequential Analysis

Abstract Objective There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. We opt to compare post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery. Method A comprehensive electronic search was conducted using PubMed/MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15th June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis was conducted. Results Ten studies consisting of 3728 patients (2098 patients with skeletonized bilateral internal mammary artery grafting and 1630 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.32, 95% CI 0.20 – 0.51, p &amp;lt; 0.00001). S-BIMA may be associated with lower late mortality, but more information is required to confirm this. Conclusions Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This makes it an important technique for use in bilateral internal mammary artery grafting for high-risk patients.

Impact of preoperative glycometabolic status on outcomes in cardiac surgery: Systematic review and meta-analysis

BackgroundHistorically, impaired glucose metabolism has been associated with early and late complicated clinical outcomes after cardiac surgery; however, such a condition is not specific to subjects with diabetes mellitus and involves a larger patient population. MethodsDatabases were screened (January 2000 to December 2020) to identify eligible articles; studies that evaluated the association between preoperative metabolic status, as assessed by glycosylated hemoglobin levels and clinical outcomes, were considered. The studies were stratified in thresholds by baseline glycosylated hemoglobin level (lower vs higher). ResultsThirty studies, involving 34,650 patients, were included in the review. In a meta-analysis stratified by glycosylated hemoglobin levels, early mortality was numerically reduced in each threshold comparison and yielded the highest reductions when less than 5.5% versus greater than 5.5% glycosylated hemoglobin levels were compared (risk ratio, 0.39; 95% confidence interval, 0.18-0.84; P = .02). Comparing higher glycosylated hemoglobin threshold values yielded comparable results. Late mortality was reduced with lower levels of glycosylated hemoglobin. Low preoperative glycosylated hemoglobin was associated with the lowest risk of sternal wound infections (risk ratio, 0.50; 95% confidence interval, 0.32-0.80; P = .003 and risk ratio, 0.53; 95% confidence interval, 0.39-0.70; P < .0001) for comparisons of less than 7.5% versus greater than 7.5% and less than 7.0% versus greater than 7.0% glycosylated hemoglobin thresholds, respectively. Additionally, levels of glycosylated hemoglobin lower than 7% were associated with reduced hospital stay, lower risk of stroke/transient ischemic attack (risk ratio 0.53; 95% confidence interval, 0.39-0.70; P < .0001), and acute kidney injury (risk ratio, 0.65; 95% confidence interval, 0.54-0.79; P < .0001). ConclusionsLower levels of glycosylated hemoglobin in patients undergoing cardiac surgery are associated with a lower risk of early and late mortality, as well as in the incidence of postoperative acute kidney injury, neurologic complications, and wound infection, compared with higher levels.

The effects of showering in 48-72 h after coronary artery bypass graft surgery through median sternotomy on wound infection, pain, comfort, and satisfaction: randomized controlled trial.

Time of showering after surgery is still a controversial issue for surgical patients and health professionals. We evaluated the effects of showering in 48-72 h after median sternotomy on sternal wound infections, pain due to sternotomy, patient comfort, and satisfaction levels. The study was a randomized controlled clinical trial. Fifty-one patients were randomly allocated (1:1) to the shower (n = 26) or non-shower group (n = 25). The patients in the shower group (intervention group) showered in the first 48-72 h after surgery and the patients in the non-shower group (control group) were not allowed to shower until their chest tube sutures were removed. They were instructed to shower on the next day after removal of the chest tube sutures. The rate of sternal wound infections was significantly lower in the shower group (n = 2, 7.7%) than in the non-shower group patients (n = 8, 32.0%; P = 0.038). A logistic regression analysis showed that early post-operative showering was protective and significantly reduced the risk of sternal wound infections independently of other variables [odds ratio (OR): 0.177; 95% confidence interval (CI): 0.033-0.940; P = 0.042]. The pain severity score was significantly lower in the shower group patients. Also, comfort and satisfaction scores were significantly higher in this group (P < 0.05). Early showering after sternotomy was found to be protective against sternal wound infections and had a positive effect on pain, comfort, and satisfaction. Clinical Trials.gov registration number NCT04250961 (https://clinicaltrials.gov/ct2/show/NCT04250961).

Major Infections after Blood Transfusion in Isolated Coronary Artery Bypass Surgery Patients: A Meta-Analysis

BACKGROUND Blood transfusion in patients undergoing coronary artery bypass surgery (CABG) remains high despite advances in perioperative blood conservation. Several studies have shown poorer clinical outcomes in isolated CABG patients who receive blood products, including an increased rate of renal failure, non-fatal myocardial infarction, and death. Our study sought to determine the impact of blood transfusion on sternal wound infections and other major infections in patients who undergo isolated CABG. METHODS We performed a systematic search using PubMed, Google Scholar, EMBASE, SCOPUS, and ClinicalTrials.gov without language restriction until May 15, 2020. A random-effects model was utilized to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI). RESULTS In patients undergoing isolated CABG, sternal wound infections [RR 1.73 (95% CI: 1.35 to 2.20; p&amp;lt;0.0001)] and overall major infections [RR 1.70 (95% CI: 1.39 to 2.08; p&amp;lt;0.0001)] were significantly higher in those who received a periprocedural blood transfusion. Thirty-day mortality was lower in patients who did not receive any transfusion [RR 2.46 (95% CI: 1.09-5.56;p=0.03)]. The test of heterogeneity was low for clinical outcomes aside from 30-day mortality. CONCLUSION Periprocedural blood transfusion is associated with an increased risk of sternal wound infections and major infections and higher 30-day mortality in patients who undergo isolated CABG Disclosures No relevant conflicts of interest to declare.

Multiple vs single arterial grafting in coronary surgery among diabetic patients: a meta-analysis

Abstract Background and aim The use of more than one arterial conduit in coronary surgery has been widely associated with better long-term results. We sought to investigate the benefits of Multiple Arterial Grafts (MAG) over Single Arterial Grafts (SAG), among diabetic patients, in short and long-term results throughout a meta-analysis of propensity score matching (PSM) studies. Methods MEDLINE and ISI Web of Science were used to find relevant literature (1960–2018). We included cohort studies with at least 200 patients and that reported one of these outcomes: long-term survival, early mortality or sternal wound infection (SWI). Survival was collected through hazard ratio (HR) along with their variance and the other endpoints using frequencies or odds ratio (OR) from the matched sample. Fixed effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Results Eleven studies were included performing a total of 9670 diabetic patients: 4833 MAG and 4837 SAG (1:1 PSM in all studies). MAG group consisted in bilateral internal mammary artery (BIMA) in 8 studies; single IMA (SIMA)+radial artery (RA) in 5 studies; and one study reported several MAG approaches: BIMA+RA+Gastroepiploic artery (GEA), SIMA+RA+GEA, SIMA+GEA or BIMA+GEA. SAG group consisted in SIMA with or without saphenous vein graft in all studies, except for one that included also patients with GEA instead of SIMA. Ten studies reported long-term survival and mean follow-up time ranged from 5 to 12 years (max. follow-up 30y). Overall, MAG had significantly improved long-term survival compared with SAG (pooled HR=0.79, 95% CI: 0.74–0.85, p&amp;lt;0.01). In-hospital mortality was reported by 6 studies (4202 patients: 2099 MAG and 2103 SAG) and occurred in 3.0% vs. 3.3% in MAG vs. SAG patients, respectively (pooled OR: 0.91, 95% CI: 0.65–1.29, p=0.60). SWI was reported by 6 studies (4432 patients: 2216 MAG and 2216 SAG) and occurred in 2.8% vs. 2.2% in MAG vs. SAG patients, respectively (pooled OR: 1.31, 95% CI: 0.90–1.92, p=0.15). Excluding one article in which MAG group consisted in IMA+RA, the remaining 5 BIMA vs. SIMA studies reported an higher risk of SWI in MAG group (pooled OR: 1.63, 95% CI: 1.07–2.49, p=0.02) Conclusion Considering PSM studies, MAG provides superior long-term survival compared to SAG in diabetic patients. This surgical technique does not implement additional risk regarding in-hospital mortality, but MAG with BIMA was associated with a higher risk of SWI in this specific subgroup of patients. Forest plot survival Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): Universidade do Porto/FMUP e FSE-Fundo Social Europeu, NORTE 2020-Programa Operacional Regional do Norte,-Programas Doutorais

Wound Infection after CABG Using Internal Mammary Artery Grafts: A Meta-Analysis.

Internal mammary arteries show better long-term patency rates than venous grafts. The use of both mammary arteries is associated with a higher risk of sternal wound infections. This meta-analysis was designed to assess the incidence of a wound healing disorder after bilateral compared with single mammary artery bypass grafting. Compared with existing meta-analysis this paper includes more current literature and one randomized controlled trial. A literature search was performed using PubMed and the Cochrane Library. The quality of the articles was assessed by the Newcastle Ottawa Scale. The odds ratio was used as a measure of the chance of developing a wound healing disorder after bilateral internal mammary artery (BIMA) surgery. Meta-analyses were performed for different subgroups. Twenty studies met the quality criteria, including one randomized controlled trial. The use of both mammary arteries significantly increased the risk of superficial (odds ratio [OR] 1.72) and deep (OR 1.75) wound healing disorder in the total population (OR 1.80) as well as in the diabetic subgroup (OR 1.38) and with both preparation techniques. The increased risk with BIMA grafting was present independently of the preparation technique (pedicled: OR 1.89, skeletonized: OR 1.37). Bilateral internal mammary artery grafting, especially in high-risk and diabetic patients, is associated with an increased risk of wound healing impairment. Skeletonized preparation does not eliminate the elevated wound healing disorder risk after BIMA use.

Skeletonized versus pedicled left internal mammary artery harvesting and risk of sternal wound infection after coronary artery bypass surgery

Background: The left internal mammary artery (LIMA) is the gold standard conduit for coronary artery bypass grafting (CABG). There are two harvesting methods, either pedicled or skeletonized. The choice of any technique must consider its complication profile, especially sternal wound infections (SWI). This study aims to evaluate and compare the occurrence of SWI after pedicled and skeletonized LIMA harvesting techniques for CABG.&#x0D; Methods: This prospective observational study included 300 patients who had CABG between 2016 and 2019. We included patients who had pedicled LIMA (n=200) in group 1 and who had skeletonized LIMA (n=100) in group 2. All patients completed a follow-up period of 3 months after CABG. The evaluation during follow-up included: sternal instability, signs of wound infection, temperature, the microbiological study of wound discharge, and chest computed tomography scan.&#x0D; Results: There was no significant differences in age (p = 0.20), male to female ratio (p = 0.43), body mass index (p = 0.12), NYHA I/II (p = 0.50), diabetes mellitus (p = 0.28), ejection fraction (p= 0.14), and EuroSCORE II (p= 0.09) between groups. No significant difference in cardiopulmonary bypass time (p = 0.24), and cross-clamp time (p= 0.19) between groups. There was a significant increase in the total operating time in skeletonized LIMA group (212.77±75.25 min vs. 190.78±55 minutes, p= 0.004). Skeletonized LIMA was significantly associated lower incidence of SWI than that with pedicled LIMA (4% vs 15.5%, p= 0.003), and non-significantly lower incidence of deep SWI (1% vs 4.5%, p= 0.11). The risk factors for SWI in patients who had pedicled IMA were obesity (OR: 13.06, 95%CI: 3.98-42.89), diabetes mellitus (OR: 10.51, 95%CI: 2.35-46.84), and excessive diathermy (OR: 12.62, 95%CI: 3.93-40.54).&#x0D; Conclusion: Obesity, diabetes, and the use of excessive diathermy for hemostasis may increase the risk of sternal wound infection with pedicled LIMA harvest compared to skeletonized LIMA in patients undergoing CABG.

Efforts to Reduce Infections in Delayed Sternal Closure Patients: A Survey of Pediatric Practice.

Pediatric patients with sternum left open after cardiac surgery experience a higher risk for sternal wound infection (SWI). These infections are costly for programs, payers, and patients and their families. Despite efforts by individual programs to reduce infections in patients undergoing delayed sternal closure (DSC), there are no established guidelines that address preventive procedures. The purpose of this study was to determine the practice of pediatric cardiac surgery programs to prevent infection in their DSC patients and if preventive measures were associated with less infections. A 33 question survey on institutional practices was sent to chief surgeons at pediatric cardiac surgery programs in the United States. Twenty-eight (35%) surgical programs responded. The mean number of pediatric cardiac bypass operations performed by programs in 2016 was 227 (range: 69-872). Data represented 6,484 patients <18 years of age who underwent cardiac surgery with 807 (12%) of those undergoing DSC. One hundred fifty-eight (2.4%) of all patients and 51 (6.3%) of the DSC patients developed a SWI. Patients with DSC who received preoperative baths were less likely to become infected (5.9% vs 15.8%; P = .015). Patients in programs with feeding protocols had fewer infections (5.7% vs 14.8%; P = .008). The results of this survey of children's cardiac surgery programs describe their practices to reduce infection rates in DSC patients. A multicenter project on wound care and closure techniques that might impact this costly complication is needed.

Does Bilateral Internal Mammary Artery Grafting Better Suit Patients With Diabetes? - Two Different Ways to Explore Outcomes.

This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.Methods and Results:Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001). Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Has Arterial Revascularization Trial [ART] burst the BITA bubble?

The 10-year outcome of the Arterial Revascularization Trial (ART) has recently been published. The study is the largest randomized study comparing bilateral internal thoracic artery (BITA) with single internal thoracic artery (SITA) as a grafting strategy for coronary artery bypass. In this review, a critical appraisal of the study has been performed where the result of the trial has been discussed along with the risk of sternal wound infections, the presence of a learning curve, and the influence of volume on outcomes. The influence of BITA grafting on other aspects like influence on hospital stay and quality of life outcomes has also been discussed.

History of Depression and Increased Risk of Sternal Wound Infection After Cardiothoracic Surgery: A Novel and Potentially Modifiable Risk Factor.

BackgroundSternal wound infection (SWI) is a leading cause of postoperative disease and death; the risk factors for SWI remain incompletely understood. The goal of the current study was to investigate the relationship between a preoperative history of depression and the risk of SWI after cardiothoracic surgery.MethodsAmong patients undergoing cardiothoracic surgery in a major academic medical center between 2007 and 2012, those in whom SWI developed (n = 129) were matched, by date of surgery, with those in whom it did not (n = 258). Multivariable logistic regression was used to examine the strength of relationships between risk factors and development of infection. History of depression was defined as a composite variable to increase the sensitivity of detection.ResultsHistory of depression as defined by our composite variable was associated with increased risk of SWI (adjusted odds ratio, 2.4; 95% confidence interval, 1.2–4.7; P = .01). Staphylococcus aureus was the most common organism isolated.ConclusionsHistory of depression was associated with increased risk of SWI. Future prospective studies are warranted to further investigate this relationship. Depression is highly treatable, and increased efforts to identify and treat depression preoperatively may be a critical step toward preventing infection-related disease and death.

Does bilateral versus single thoracic artery grafting provide survival benefit in female patients?

Bilateral internal thoracic artery (BITA) grafting is associated with improved survival, but this technique is reluctantly used in women due to an increased risk of sternal wound infection. The aim of this study was to compare the long-term survival of women who underwent BITA grafting and single internal thoracic artery (SITA) grafting. We performed a retrospective analysis of 556 consecutive female BITA patients and 685 female SITA patients. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic lung disease, chronic renal failure, peripheral vascular disease and cerebral vascular disease). Operative mortality showed a trend towards a benefit for BITA (2.9% vs 5.0% for SITA, P = 0.06). The sternal wound infection rates were similar (3.4% vs 2.9%, P = 0.6); however, the occurrence of stroke was significantly lower in the SITA group (3.4% vs 1.2%, P = 0.007). The median survival of the BITA group was significantly better {13.8 years [95% confidence interval (CI) 12.8-14.9] vs 10.3 years [95% CI 9.6-11.1], P = 0.001}. After propensity score matching (491 pairs), the assignment to BITA was not associated with increased early mortality or complication rates, and the choice of BITA grafting was associated with better survival [14.5 years (95% CI 13.3-15.6) vs 11.8 years (95% CI 10.7-12.9)]. Only the choice of conduits was associated with increased late mortality (multivariable analysis, hazard ratio 1.28, 95% CI 1.024-1.591; P = 0.03). The low early mortality and complication rate, and the long-term survival benefit of BITA compared to SITA grafting, support the use of BITA grafting in women.

Glycated Hemoglobin and the Risk of Sternal Wound Infection After Adult Cardiac Surgery: A Systematic Review and Meta-Analysis

Increased glycated hemoglobin (HbA1c) has been shown to increase the risk of mortality, myocardial infarction, and stroke after cardiac surgery, whereas its impact on the development of sternal wound infection (SWI) is less clear. A systematic review and meta-analysis were performed to evaluate the impact of preoperative HbA1c levels on the occurrence of SWI after adult cardiac surgery. Fourteen studies including 17,609 patients fulfilled the inclusion criteria and were included in this analysis. Diagnostic test meta-analysis of studies evaluating baseline HbA1c cut-off values ranging from 6% to 7% DCCT units (42-53 mmol/mol IFCC units) showed that the diagnostic odds ratio for deep SWI was 3.02 (95% confidence interval [CI] 2.10-4.35), while the diagnostic odds ratio for any SWI was 2.81 (95% CI 2.02-3.93). Binary meta-analysis confirmed that baseline HbA1c cut-off values ranging from 6% to 7% increased the risk for deep SWI (pooled incidence 2.7% vs 0.8%, risk ratio [RR] 3.01, 95% CI 2.32-3.90, I2 0%). Six studies included only diabetics and their pooled RR for deep SWI was 2.94 (1.59-5.45, I2 0%). Nine studies evaluated an HbA1c cut-off value of 7% and their RR for deep SWI was 3.22 (95% CI 2.38-4.37, I2 0%). The RR for any SWI was 2.92 (95% CI 2.42-3.53, I2 0%). This pooled analysis showed that the risk of SWI is substantially increased when preoperative HbA1c levels are over 6-7%. Future studies should evaluate whether postponing surgery for optimization of the glycemic control can reduce the risk of SWI in patients with increased levels of HbA1c.

Correction: Are two internal thoracic grafts better than one in patients with chronic obstructive lung disease? Analysis of 387 cases between 1996-2011.

[This corrects the article DOI: 10.1371/journal.pone.0201227.].

Coronary Artery Bypass Grafting using Bilateral Internal Thoracic Arteries through a Left-Sided Minithoracotomy: A Single-Center Starting Experience.

Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) is associated with the best long-term survival. However, using BITA increases the risk of sternal wound infections with conventional sternotomy. We describe here our initial results of minimally invasive CABG (MICS-CABG) using BITA. Patients were operated through an incision similar to that of standard minimally invasive direct CABG. All operations were performed off-pump. We evaluated patient's quality of life (QoL) using the Medical Outcomes trust, 36-Item Short Form Health Survey (SF-36). Between February 2016 and August 2017, we performed 21 cases of MICS-CABG using BITA. There was no intraoperative complication and no conversion to sternotomy or to on-pump. Two patients required reexploration through the same minithoracotomy for postoperative bleeding. Two cases of early postoperative graft failure were identified. There was no stroke or in-hospital mortality. The median duration of follow-up was 13 months, with a maximum of 19 months. Relief of angina was achieved in all patients. There was one readmission for superficial wound infection, which was conservatively treated. An 84-year-old man died 4 months after the operation. The remaining 20 patients attested good QoL with the SF-36 questionnaire. Myocardial revascularization using BITA can be safely achieved off-pump through a left-sided minithoracotomy with good postoperative and short-term outcomes.