Sternal Dehiscence Research Articles

818 Impaired clinical outcome and increased postoperative complications in COVID-19 patients undergoing cardiopulmonary bypass

ObjectivePrevious studies reported unfavorable results in COVID-19 patients who underwent cardiac surgery. Complications most frequently observed were respiratory failure and higher incidence of thromboembolic events. We present our single-center experience in patients with perioperative diagnosis of COVID-19 infection undergoing cardiac surgery with extracorporeal circulation.MethodsIn this observational matched case-control (propensity match 1:2) study, we collected data of patients undergoing open heart cardiac surgery from January 2020 to May 2021, having positive perioperative diagnosis of COVID-19 infection confirmed by polymerase Chain Reaction-PCR (study group). Patients were compared with 56 corresponding controls (control group) who matched for age, sex, body mass index (BMI) and Euro-Score II.ResultsIn the study period 1060 patients underwent cardiac surgery with cardiopulmonary bypass (CPB). Among them, 28 consecutive patients, aged 70.1±9.3 years, had perioperative diagnosis of COVID-19 infection. Four (14%) patients underwent emergency surgery for type-A aortic dissection, 2 (7%) patients died in the Intensive Care Unit for severe respiratory failure, shock and multiple organ failure. Significant bleeding complications occurred in 14 (50%) patients in the study group (vs 6% in the control group, p=<0.05). In the study group, 11 (39%) patients required early surgical reexploration for bleeding, 5 presented cardiac tamponade, 5 (18%) underwent multiple surgical revisions for recurrent bleeding. Three (11%) patients required late chest drainage of a massive sero-hemorrhagic pleural effusion, 1 (4%) presented late postoperative intracranial hemorrhage. Fourteen (50%) patients had severe thrombocytopenia (vs 9% in the control group, p=<0.05). In the study group blood components transfusion and procoagulant drugs administration increased (79% and 78% vs 18% and 11% in the control group, respectively, p=<0.05). In the study group 6 (21%) patients presented postoperative acute renal failure (2% in the control group, p=<0.05), 7 (25%) acute respiratory failure (p=<0.05) requiring prolonged postoperative orotracheal intubation. Sternal dehiscence was observed in 4 (14%) patients in the study group (vs 4% in the control group, p=< 0.05). Complications significantly influenced hospital stay length (20 ± 3.1 vs 8.1 ± 3.9 days, p=< 0.05). In the multivariable logistic regression model the SARS-CoV-2 infection and renal failure were independent factors associated with severe postoperative complications (p=<0.01).ConclusionsClinical outcome of open heart cardiac surgery patients with perioperative COVID-19 infection appears significantly impaired in terms of mortality and postoperative complications. CPB-related inflammatory reaction could likely exacerbate the deleterious effect of COVID-19 on the respiratory and renal systems, as well as on the coagulation pathways. Early and late hemorrhagic complications were very frequent with significantly increased surgical reexplorations for bleeding, a higher incidence of severe thrombocytopenia, of blood components transfusion and procoagulant drugs administration. The increased surgical risk should suggest a cautious attitude in indicating open heart surgery in patients with perioperative COVID-19 infection and surgery should be limited to not postponable or to urgent cases.

Transverse sternal plating in secondary sternal reconstruction: Single-center clinical experience

Objectives: This study reviews five-years’ experience of transverse sternal plating in secondary sternal reconstruction in our clinic. Materials and methods: We retrospectively reviewed our experience with transverse sternal plating using a titanium sternal plate system between January 2015 and December 2019. During this period, a total of 31 sternal plating operations for secondary sternal closure after cardiac surgery were performed. Results: During the five years of the study, 31 patients underwent sternal plating. There were 20 males and 11 females in the group. The average age was 65.4±10.2 years with a body mass index (BMI) of 27.5±2.9 kg/m2 . Twenty-six (83.9%) were diabetics, 23 (74.2%) active smokers, 11 (35.5%) had chronic obstructive pulmonary disease (COPD) and two (6.5%) had renal failure. Conclusion: Titanium plate fixation is an effective method to stabilize complicated sternal dehiscence. It is a simple and safe technique without risks. More comprehensive research is required to address the indications, benefits, and complications of sternal plating.

OV09 ROBOTIC REPAIR OF SUBXIPHOID INCISIONAL HERNIA POST CABG

Abstract Aim A median sternotomy that extends toward the epigastric area can weaken the upper abdominal wall and result in the development of subxiphoid incisional hernia. We aim to assess the efficacy and the feasibility of repair of subxiphoid incisional hernia post CABG robotically. In this video; we will also review the surgical technique and the steps for robotic repair of subxiphoid incisional hernia Material and Methods 57-year-old female presented with subxiphoid swelling post CABG in 2019. Her surgery was complicated with sternotomy wound infection with VAC dressing application and ARDS with prolonged intubation. She had 5x7 cm hernia defect that showed on the CT thorax along with sternal wound dehiscence. She underwent robotic repair of her hernia with phasix mesh and recovered well after surgery. Results The subxiphoid hernia is known for its repair complexities and high recurrence rate because the subxiphoid area is a complex structure consisting of boney structures, the rectus abdominis muscles, linea alba, and the diaphragm. The Da Vinci platform allows for accessing hard-to reach area with enhanced precision in dissection and superior dexterity compared to laparoscopy. The Robotic platform allows for manipulation of the camera to assess and operate on the abdominal wall with ease as compared to laparoscopy. Conclusions robotic repair of subxiphoid incisional hernia with mesh is safe and effective method of repair. There are no short-term or long- term side effects of the procedure with no recurrence at 6 months follow up.

Comparison of Two Sternal Closure Techniques Based on Risk Factors: A Prospective, Observational Study.

Background Stainless steel wires are still commonly used as a sternum closure technique. However, it can cause fatal complications due to rupture and dehiscence. It was anticipated that the sternal Cable System (Pioneer Surgical Technology Inc., Marquette, MI, USA) could provide a better sternal fixation and reduce the possible complications. Materials and Method. A total of 100 patients (57 male, 43 female) at high risk of dehiscence were included in this prospective observational study. Among those with EuroSCORE value of 4 and above, patients with chronic lung disease, chronic kidney disease, diabetes mellitus, obesity, smoking, body mass index, advanced age, and resurgery were operated in two separate centers. Standard steel wires (n: 51) used for sternotomy were compared with the sternal cable (n: 49). Early and late sternal dehiscence rates were compared in the study. The relationship between risk factors causing dehiscence and both methods was assessed statistically. Results Early dehiscence rates were 6.4% in those closed with a sternal cable (n: 3) and 11.8% in those closed with a sternal wire (n: 6) (p < 0.05)). In risky patients, body mass index was the most determining parameter in terms of sternum dehiscence risk. Conclusion In risky patients, we recommend the sternal cable system as a good and reliable closure technique to achieve a more stable and compact sternum.

Ultra Sound Guided Erector Spinae Plane Block for Perioperative Analgesia in Post Coronary Artery Bypass Grafting Sternal Dehiscence (Type 2b) Patient Posted for Pectoralis Major Flap

Sternal dehiscence is a grave complication after cardiac surgery. Deep sternal dehiscence usually requires debridement and flap coverage as the mainstay of management. The perioperative period is considered very challenging and the anesthetic technique has a direct impact on the risk of perioperative complications. Perioperative pain management is usually carried out with the help of regional anesthetic techniques as they offer various benefits for this patient population, including the provision of high-quality analgesia, reduced requirements for opioids and nonsteroidal anti-inflammatory drugs, and reduced autonomic system activation. Conventionally, regional anesthesia techniques such as epidural and paravertebral blocks have been shown to provide effective analgesia and enhance postoperative recovery. However, these techniques were associated with minimal but unacceptable complications. Ultrasound-guided erector spinae plane (ESP) block is a recently described technique providing thoracic analgesia. This is the first case report to our knowledge, which describes the use of ESP block as perioperative analgesic technique for pectoralis flap in a high-risk cardiovascular patient.

STERNOTOMY CLOSURE AFTER HISTORY OF MAJOR STERNAL RESECTION FOR MALIGNANT DISEASE

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sternal closure after resections for the benign or malignant disease has always been a topic of discussion based on the need for adequate closure and coverage of the chest. The dreaded complication of deep space infection or sternal dehiscence after a sternal resection is a real concern among the cardiothoracic surgery community as these complications can lead to significant morbidity and mortality. We present a case of a 69-year-old female with a history of a large left inferior sternal resection due to malignant disease undergoing closure of her sternum after an on-pump coronary artery bypass. CASE PRESENTATION: A 69-year-old female with a past medical history of hypertension, depression, and smoking presented to the hospital with a chief complaint of chest pain. The patient was found to have shortness of breath with pain radiating to both of her arms. She was found to have a STEMI with an acute inferior wall infarction on EKG and an elevated troponin of 748. The patient was taken emergently to the cath lab and was found to have multivessel coronary artery disease with a preserved left ventricular function. The patient was continued on heparin and evaluated by the cardiac surgery team. She was taken for coronary artery bypass with bypass of the obtuse marginal and left anterior descending arteries. Upon opening the chest, we noted she had a large piece of her left inferior sternum missing from her previous surgery. The manubrium remained intact, the decision was made at the time of her chest closure to use a sternal locking system on the manubrium and upper portion of her sternum for added strength and support of her previous sternal resection. The patient's postoperative course was uneventful, and she was discharged home. On clinic follow up she had excellent healing of her sternal wound with no signs of dehiscence. DISCUSSION: Closure of a sternotomy site after resection of a large portion of the sternum is a major risk factor for potential noninfectious dehiscence that could lead to infection especially if the bone quality is poor or if there is minimal sternum left to close the chest. There is limited data about the closure of a sternotomy after a major portion of the sternum has been previously resected due to malignant disease in the past. When minimal manubrium or sternum remains after resection, we recommend plating for added strength of the sternal closure. CONCLUSIONS: Sternal dehiscence with complications is a major concern after sternotomy is performed. The risk for sternal dehiscence is even greater when the patient has had a previous sternal resection with minimal sternum remaining. We highly recommend using a sternal plate locking closure device when closing a previous sternum that has had a major sternal resection. The plating system provides stronger closure and will help to avoid the dreaded complication of dehiscence even when there is minimal sternum remaining. REFERENCE #1: Adel M., F. Alhalawani, et al. A review of sternal closure techniques: J Biomater Appl.2013 Nov 483-497 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response

Deep Wound Infection in Pediatrics after Open Cardiac Surgery

Abstract Surgical site infection (SSI) is a serious complication requiring prolonged hospitalization, intravenous antibiotics, wound care and dressings resulting in increased cost and resistant bacteria. In pediatric cardiac surgery, Median sternotomy is the most frequently used incision for the correction of congenital anomalies. Sternal wound infections (SWIs) are well described complications of cardiac surgery and can occur in 3% to 8% of children. Furthermore, the mortality rate can increase 2-fold after SSIs. Also, SSIs are associated with an increased length of hospital stay, readmissions, and higher health care expenditures. Mediastinitis is a retrosternal wound infection frequently associated with a macroscopically sternal osteomyelitis. Mediastinitis is uncomfortable for patients, is poorly accepted by parents, leads to a prolonged hospital stay repeated surgery and prolonged antibiotic therapy. Mediastinitis are costly for patients, providers, and health-care institutions. In A recent survey among congenital heart programs, the incidence of mediastinitis has been reported to occur in 0.2–1.4%. Gram-positive cocci are the most common pathogen. Gram negative organisms are increasingly recognized, especially in neonates, and are related to delayed sternal closure. Fungal organisms are not infrequently found. Mediastinitis generally presents 2–3 weeks after cardiac surgery. Child often appear irritable, tired, and febrile. The incision is erythematous and painful. Wound separation and purulent drainage from the incision are frequent. Some but not all will also have sternal instability or dehiscence. Associated bacteremia is not uncommon, present in up to 40% of patients. Postoperative mediastinitis is a life-threatening infection and increase health expenditure. Young age, malnutrition, hypothermia, hyperglycemia, longer duration of surgery, long time of delayed sternal closure, postoperative low cardiac output and long ICU stay were a risk factor of mediastinitis. Stick to1999 CDC's Guideline for prevention of surgical site infection and their update in 2017 especially proper timing of antibiotic prophylaxis and post-operative blood glucose management is important in prevention of these life-threatening complication. procalcitonin can be useful biologic marker of infection. Management of mediastinitis consist of debridement and culture-based antibiotics. Primary closure over mediastinal drain or high vacuum drain gave good result, less time consuming, more economic and more cosmetic. Vacuum assisted closure gave excellent result, but more time consuming, less economic and delayed closure is necessary. Larger studies are needed to compare both techniques in effectiveness and coast benefit.

Does Sternal Cable System Prevent Sternal Complications after Revision Sternal Surgery?

To determine the efficacy of a sternal wire system in secondary sternal dehiscence after repeat closure of the sternum, following surgical revision after open heart surgery. Case-control study. Department of Cardiovascular Surgery, Zonguldak Bülent Ecevit University, Zonguldak, Turkey; and Turkey Yuksek Ihtisas Training and Research Hospital, Turkey, from January 2015 to May 2019. Patients, who underwent open heart surgery with median sternotomy, were included in this retrospective study. The patients were divided into two groups, according to the sternal closure material. The time of the sternal reconstruction surgery, because of sternal dehiscence, fracture, broken sternal wire(s) or cable(s) after the first revision surgery, was noted for each patient. A total of 389 patients were identified. Group 1 included 72 (50%) patients whose sternums were closed with a sternal cable system; and Group 2 included 72 (50%) patients whose sternums were closed with conventional steel wires after propensity matching. The duration of cardiopulmonary bypass, number of intra-aortic balloon pumps used, and number of extracorporeal membrane oxygenators used were significantly higher in Group 1 (p = 0.007, p = 0.034, and p = 0.028, respectively). The number of emergency operations was significantly higher in Group 2 (p = 0.021). There was no significant difference in terms of secondary sternal dehiscence between the groups (p = 0.366). Application of the sternal wire system in revisional open heart surgery is not more effective than conventional steel wire at preventing secondary sternal dehiscence. Key Words: Sternal dehiscence, Sternal cable, Sternal wire, Open heart surgery, Postoperative revision.

Routine early postoperative computed tomography angiography after coronary artery bypass surgery: clinical value and management implications.

Computed tomography angiography (CTA) is broadly used for long-term follow-up of graft patency after coronary artery bypass graft surgery (CABG). However, its clinical value in the early postoperative setting has not been established yet. We evaluated the benefit of adding CTA to the routine clinical work-up after CABG on patient management. A total of 305 consecutive patients (269 males, median age 68 years) underwent CABG and postoperative CTA with a median of 6 days after surgery. Graft patency and additional imaging findings were assessed and their influence on diagnosis and clinical management was evaluated. Graft occlusion or high-grade stenosis was found in 15% of the patients. Additional findings were reported in 44% of the patients, including pericardial (2%) and pleural effusion (27%), large pneumothorax (11%), pulmonary infection (4%), cardiac or vascular thrombus (2%), pulmonary embolism (2%), sternal dehiscence (1%) and additional incidental findings requiring follow-up (6%). CT findings initiated new diagnostic and/or therapeutic measures in 15% of the patients, 47% of those with diseased grafts and 19% of patients with non-graft-related findings. No adverse events related to CTA were documented. Early routine postoperative assessment of CABG with CTA reveals both cardiac and non-cardiac findings with a high frequency, affecting clinical management in a substantial proportion of patients.

What is the impact of a previously failed Robicsek repair in the subsequent treatment of sternal dehiscence with thermoreactive nitinol clips?

In this study, we conducted a retrospective review of patients at our institution with noninfectious sternal dehiscence (NISD) after median sternotomy who received thermoreactive nitinol clips (TRNC) treatment during a 10-year period. The purpose of the study was to analyze the impact of previous Robicsek repair on the later treatment of sternal dehiscence with TRCN to establish which method was better in high-risk patients with NISD. Between December 2009 and January 2020, out of 283 patients with NISD who underwent refixation, we studied 34 cases who received TRNC treatment. We divided these 34 cases into two groups: patients who had a previously failed Robicsek procedure before TRNC treatment (group A, n = 11) and patients who had been directly referred to TRCN treatment (group B, n = 23). High-risk patients were defined as those having three or more risk factors. Postoperative complication rate was significantly higher in group A (p = .026). Hospitalization duration was significantly longer in group A due to the higher complication rate (p = .001). Operative time was significantly shorter and blood loss was significantly lower in group B (p = .001). The Robicsek procedure is considered an effective method in the treatment of NISD but, in case of its failure, subsequent TRNC treatment might become cumbersome in high-risk patients. In our study, a previously failed Robicsek procedure caused significantly higher morbidity, additional operative risk and lower success rate in later TRNC treatment of high-risk cases. Ultimately, we speculate that a direct TRNC treatment for NISD is favorable in high-risk patients.

Combination plate and band fixation for primary closure in bilateral lung transplantation.

Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.

Development of a new sternal dehiscence prediction scale for decision making in sternal closure techniques after cardiac surgery

BackgroundAfter sternotomy, the spectrum for sternal osteosynthesis comprises standard wiring and more complex techniques, like titanium plating. The aim of this study is to develop a predictive risk score that evaluates the risk of sternum instability individually. The surgeon may then choose an appropriate sternal osteosynthesis technique that is risk- adjusted as well as cost-effective.MethodsData from 7.173 patients operated via sternotomy for all cardiovascular indications from 2008 until 2017 were retrospectively analyzed. Sternal dehiscence occurred in 2.5% of patients (n = 176). A multivariable analysis model examined pre- and intraoperative factors. A multivariable logistic regression model and a backward elimination based on the Akaike Information Criterion (AIC) a logistic model were selected.ResultsThe model showed good sensitivity and specificity (area under the receiver-operating characteristic curve, AUC: 0.76) and several predictors of sternal instability could be evaluated. Multivariable logistic regression showed the highest Odds Ratios (OR) for reexploration (OR 6.6, confidence interval, CI [4.5–9.5], p < 0.001), obesity (body mass index, BMI > 35 kg/m2) (OR 4.23, [CI 2.4–7.3], p < 0.001), insulin-dependent diabetes mellitus (IDDM) (OR 2.2, CI [1.5–3.2], p = 0.01), smoking (OR 2.03, [CI 1.3–3.08], p = 0.001). After weighting the probability of sternum dehiscence with each factor, a risk score model was proposed scaling from − 1 to 5 points. This resulted in a risk score ranging up to 18 points, with an estimated risk for sternum complication up to 74%.ConclusionsA weighted scoring system based on individual risk factors was specifically created to predict sternal dehiscence. High-scoring patients should receive additive closure techniques.

Use of longitudinal rigid sternal fixation in prevention and treatment of wound complications among high-risk patients after cardiac surgery.

Traditionally, wire cerclage closure has been used to reapproximate the sternum after cardiac surgery. Recent evidence suggests that rigid sternal fixation may reduce the risk of wound complications. The aim of this study was to analyze our 10-year experience with longitudinal rigid sternal fixation (LRSF) for prevention and treatment of wound complications in high-risk patients. We reviewed data from cardiac surgical database of patients who underwent LRSF, and compared their outcomes with conventional wire cerclage closure (CWS). Among these 319 patients were designated as having high-risk for the development of deep wound complications and received primary LRSF (treatment group). We matched their outcomes with 319 patients who met indications for LRSF however, underwent standard closure with CWC (control group). Both groups were comparable regarding preoperative and intraoperative variables. The benefit observed among matched patients who had undergone LRSF was largely driven by a decreased rate of deep wound infections (0.63% vs. 3.45% vs., p < .01), 30-day mortality (1.57% vs. 5.96%) and hospital length (8.2 vs. 11.7 days) p < .05, respectively. A multivariate logistic regression analysis found four independent risk factors for the development of sternal dehiscence. Sternal healing evaluated by computerized tomography scan using 6-point scale at 3 months after surgery was superior in LRSF patients. Pain scores were significantly lower in LRSF patients as well. In patients with an increased risk for sternal instability and wound infections after cardiac surgery, sternal reconstruction using LRSF is an effective technique to stabilize sternum for preventive and treatment purposes.

Steroid use for recovery of advanced atrioventricular block immediately after valvular surgery (survival): a randomized clinical trial

Abstract Funding Acknowledgements Type of funding sources: None. Background Limited inconsistent evidence support use of steroids in recovery of atrioventricular block (AVB) after trans-catheter aortic valve implantation. However, there is no study to examine the efficacy of steroids in recovery of high-grade AVB following valvular surgery. Purpose To assess the effect of high-dose dexamethasone on recovery of advanced AVB following valvular heart surgery. Methods In this randomized controlled trial, patients with advanced postoperative AVB (either Mobitz type II or third degree) were randomly assigned to receive either dexamethasone (0.4 mg /kg, maximum 30 mg /day in three divided doses) intravenously for three days or conservative care only. Primary endpoint was recovery rate in day five since randomization. Secondary endpoints were recovery rate in day 7 and day 10, cumulative AVB time, PPM implantation rate, length of stay in critical care units, and post-operative major adverse events (MAE) during one month. We defined MAE as composite of all-cause mortality, all-type infections, major bleeding, prolonged sternal dehiscence, new stroke, postoperative MI, complicated uncontrolled hyperglycemia and readmission for decompensated heart failure. Results We enrolled 139 subjects (48.9% male) with mean age of 59.9 years who were randomly allocated to intervention group (n= 69) and control group (n= 70). Dexamethasone led to higher recovery rates at day 5 (82.6% vs. 62.9%, P= 0.009) and day 7 (88.4% vs. 61.4%, P&amp;lt; 0.0001) respectively. Random 24-hours ECG Holter monitoring of patients at day 5 revealed the same results and confirmed the superiority of dexamethasone for recovery of AVB (80.5% vs 61.2%, respectively, P = 0.024). Although this benefit ceased at day 10 (83.05 vs 78.6 %, P = 0.547), Generalized Estimating Equation analysis for recovery over 10 days favored intervention (odds ratio: 2.56, 95% CI: 1.27- 5.15, P = 0.008). Median cumulative AVB time was shorter in dexamethasone group compared to control group (41 hours vs 64 hours, P = 0.044). PPM implantation rates were similar between the dexamethasone and control groups (15.9% vs 17.1 %, respectively, P = 0.849). Median length of stay in ICU (10 days vs 12 days, P= 0.03) and MAE (17.4 % vs 25.7%, P = 0.133) tended to be lower with dexamethasone. Conclusion Our findings suggest that dexamethasone may serve as a safe and effective medication to improve recovery of advanced AVB after valvular surgery. Further studies are needed to confirm these findings, particularly regarding subsequent PPM implantation rate.

Sternal closure in patients with the high risk of sternal dehiscence

The objective was to evaluate the efficacy of sternal closure using the «double twist» technique.Methods and materials. The study included 37 patients with risk factors for sternal dehiscence (obesity, diabetes, chronic obstructive pulmonary disease). The patients were divided into 2 groups. In the first group (n=12), «double twist» technique was used. In patients of the second group (n=25), osteosynthesis was performed using standard technique (single wire ligatures). The efficacy of the «double twist» sternal closure was evaluated on the basis of clinical examination and multispiral computed tomography of the chest.Results. In the early postoperative period, the sternal dehiscence, which required re-operation was detected in 12 % after standard sternal closure. Sternum was stable in all of the patients of «double twist» group (p=0.211). No deep sternal infection was observed in both groups. In the follow-up (up to 6 months), there were no clinical and tomographic sings of delayed sternal dehiscence or infection in «double twist» group.Conclusions. Sternal closure using the «double twist» technique provides reliable fixation of the sternum in patients with the risk of its dehiscence.

Interlocking Multi-Twisted Wires Versus Interrupted Simple Sternal Wires for Closure of Median Sternotomy.

Although closure of a sternotomy incision is usually a simple procedure, failure to do so (sternal dehiscence) is a serious complication and is an independent factor that poses a high degree of morbidity or mortality after open heart surgery. Instability of the bone fragments can lead to complete sternal breakdown, sternal wound infection, and mediastinitis. The stainless-steel encircling wire used as either interrupted simple sutures or as figure of eight sutures is the current standard method of median sternotomy closure. Interlocking multi-twisted sternal wire closure is an alternative that provides rigid sternal fixation. We aim to identify the best method of sternal closure in order to implement it as a standardised protocol for our department. Two-hundred patients aged 18-70 years were undergoing cardiac surgeries at Ain Shams University hospitals. They were divided into two groups: Group I included 100 patients with sternal closure using simple wire, and group II included 100 patients with sternal closure using interlocking multi-twisted wires. The day 7, 1 month, and 3 months sternal instability, superficial wound infection, ventilation time, cross-clamp time, length of ICU stay, and length of hospital stay were analyzed. The incidence of sternal instability on the 7th day, 1 month, and 3 months was significantly higher in the simple wire closure group (P < 0.05). However, incidence of superficial wound infection, length of ICU stay, and duration of mechanical ventilation were comparable between the two groups. The interlocking multi-twist is a safe, effective, and easily reproducible method for preventing sternal dehiscence.

Prosthetic Arch Branch Graft Injury by a Fractured Sternal Wire: A Word of Caution

A 74-year-old man with a history of bronchial asthma underwent total arch replacement and coronary artery bypass grafting. He was discharged without any major complications except for postoperative coughing attacks, which caused a third sternal wire fracture and partial sternal dehiscence (Figure 1A, Figures 2A and D). He was asymptomatic and without sternal instability at 3 months after surgery. However, chest radiography (CXR) revealed migration of the fractured sternal wire (Figure 1B), and computed tomography (CT) showed close contact between the edge of the fractured sternal wire and the arch branch graft to the left subclavian artery (LSCA) (Figures 2B and E).

Predictors of mortality and adverse events in patients with infective endocarditis: a retrospective real world study in a surgical centre

PurposeMortality in infective endocarditis (IE) is still high, and the long term prognosis remains uncertain. This study aimed to identify predictors of long-term mortality for any cause, adverse event rate, relapse rate, valvular and ventricular dysfunction at follow-up, in a real-world surgical centre.MethodsWe retrospectively analyzed 363 consecutive episodes of IE (123 women, 34%) admitted to our department with a definite diagnosis of non-device-related IE. Median follow-up duration was 2.9 years. Primary endpoints were predictors of mortality, recurrent endocarditis, and major non-fatal adverse events (hospitalization for any cardiovascular cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), and ventricular and valvular dysfunction at follow-up.ResultsMultivariate analysis independent predictors of mortality showed age (HR per unit 1.031, p < 0.003), drug abuse (HR 3.5, p < 0.002), EUROSCORE II (HR per unit 1.017, p < 0.0006) and double valve infection (HR 2.3, p < 0.001) to be independent predictors of mortality, while streptococcal infection remained associated with a better prognosis (HR 0.5, p < 0.04). Major non-fatal adverse events were associated with age (HR 1.4, p < 0.022). New episodes of infection were correlated with S aureus infection (HR 4.8, p < 0.001), right-sided endocarditis (HR 7.4, p < 0.001), spondylodiscitis (HR 6.8, p < 0.004) and intravenous drug abuse (HR 10.3, p < 0.001). After multivariate analysis, only drug abuse was an independent predictor of new episodes of endocarditis (HR 8.5, p < 0.001). Echocardiographic follow-up, available in 95 cases, showed a worsening of left ventricular systolic function (p < 0.007); severe valvular dysfunction at follow-up was reported only in 4 patients, all of them had mitral IE (p < 0.03).ConclusionsThe present study highlights some clinical, readily available factors that can be useful to stratify the prognosis of patients with IE.

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.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy.

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.