Sternal Infection Research Articles

Clinical study of an outbreak of postoperative mediastinitis caused by Serratia marcescens in adult cardiac surgery

Nosocomial infection caused by Serratia marcescens after cardiac surgery is rare but causes high rates of morbidity and mortality. Knowledge about postoperative mediastinitis due to S. marcescens is limited. The purpose of this work was to study the clinical presentation, management and outcome of an outbreak of postoperative sternal infection due to S. marcescens. During a 7-week period, a total of 54 patients underwent open heart procedures in our hospital. A postoperative wound infection caused by S. marcescens was diagnosed in 10 patients. We performed a clinical study to investigate patient characteristics and outcomes as well as the possible source of the infection. The mean age of the infected patients was 74.5 ± 10 years. Mediastinitis was present in 6 cases, superficial wound infection in 3 and isolated bacteraemia in 1. Purulent exudate through the sternal incision was observed in all infected cases except in 1 patient, who presented only with bacteraemia. Serratia marcescens was isolated from the samples taken from all infected wounds. The mean time elapsed between the operation and the isolation S. marcescens was 5.9 ± 2.4 days. Response to treatment was favourable in all cases except 1, who died. Contamination of the aqueous chlorhexidine solution used to prepare the patients' skin with S. marcescens was reported. Microbiological studies demonstrated that S. marcescens strains isolated from patients and from the aqueous chlorhexidine solution belonged to the same clone. The use of an aqueous chlorhexidine solution contaminated with S. marcescens caused an outbreak of postoperative sternal wound infections. The time elapsed between wound contamination and signs of infection was brief, but the systemic inflammatory response and tissue necrosis were limited. Alcohol-based solutions are recommended for the prevention of surgical site infections.

Comparison of Glycemic Variability Indices: Blood Glucose, Risk Index, and Coefficient of Variation in Predicting Adverse Outcomes for Patients Undergoing Cardiac Surgery

Fluctuations in blood glucose (glycemic variability) increase the risk of adverse outcomes. No universally accepted tool for glycemic variability exists during the perioperative period. The authors compared 2 measures of glycemic variability-(1) coefficient of variation (CV) and (2) the Blood Glucose Risk Index (BGRI)-in predicting adverse outcomes after cardiac surgery. Prospective, observational study. Single-center, teaching hospital. A total of 1,963 adult patients undergoing cardiac surgery. None. Postoperative blood glucose levels were measured hourly for the first 24 hours and averaged every 4 hours (4, 8, 12, 16, 20, and 24 hours). Glycemic variability was measured by CV and the BGRI. The primary outcome, major adverse events (MAEs), was a predefined composite of postoperative complications (death, reoperation, deep sternal infection, stroke, pneumonia, renal failure, tamponade, and myocardial infarction). Logistic regression models were constructed to evaluate the association. Predictive ability was measured using C-statistics. Major adverse events were seen in 170 (8.7%) patients. Only the fourth quartile of CV showed association (odds ratio [OR] 1.91; 95% confidence interval [CI] [1.19-3.14]; p = 0.01), whereas BGRI was related significantly to MAE (OR 1.20; 95% CI [1.10-1.32]; p < 0.0001). The predictive ability of CV and BGRI increased on adding the standard Society of Thoracic Surgeons (STS) risk index. The C-statistic for STS was 0.68, whereas STS + CV was 0.70 (p = 0.012) and STS + BGRI was 0.70 (p = 0.012). Both CV and the BGRI had good predictive ability. The BGRI being a continuous variable could be a preferred measure of glycemic variability in predicting adverse outcomes (cutoff value 2.24) after cardiac surgery.

Post-Surgical Outcomes After Sternal Closure Using Zipfix Band and Steel Wires

Median sternotomy is the most commonly used and the standard way of an incision after cardiothoracic procedures. The use of stainless steel wire has been considered the gold standard in the sternal closure system; however, increasing postoperative complications have caused other options. The aim of this study is to understand the combined effect of the ZipFix bands with steel wires on postoperative outcomes after sternal closure. This is a real-world evidence study of patients treated using the ZipFix band and steel wires. The sternal closure is performed by fixing of manubrium with straight simple wires, followed with ZipFix 3 or 4 spaces. Demographic characters of patients using the ZipFix band and steel wire and their relation to sternal infections, wound dehiscence, and post-surgical outcomes are studied. From gathered evidence, 2% of patients’ cases were complicated with the incidence of sternal infections. Ninety-nine percentage of patients had a stable and healthy wound while 1% of patients showed sternal wound dehiscence. The mean duration of hospital and intensive care unit stay was 8.53 (± 4.84) days and 3.58 (± 5.01) days respectively. The use of the sternal ZipFix system in combination with stainless steel wire is found to be effective in reducing post-surgical complications.

Frequency of deep infection of the sternal wound in diabetic patients utilizing skeletonized versus pedicled harvesting technique of internal thoracic artery after CABG surgery.

Objectives: After coronary artery bypass graft (CABG) surgery, infection of the sternum is a serious issue as it would adversely affect the mortality of patient. Left internal thoracic artery (LITA) has significant benefits but after its utilization occurrence of sternal infection is documented especially in diabetic patients due to impairment in blood flow of sternum. Our objective was to document the frequency of deep infection of the sternal wound in patients with diabetes utilizing skeletonized versus pedicled harvesting technique of the left ITA after CABG Surgery in our population. Study Design: An observational study was retrospectively done. Setting: National Institute of Cardiovascular Diseases, Karachi. Period: January 2013 to October 2015. Material and Methods: The sample size of the study was determined to be a total of two hundred and twenty patients who had primary, isolated and elective CABG surgery. One hundred and ten patients were included in whom skeletonized left ITA was utilized and in one hundred and ten patients pedicled left ITA was utilized. We used the statistical Chi square test and p &lt; 0.05 was considered significant. Results: Deep infection of the sternal wound occurred in 3.64% of the patients with diabetes in whom the pedicled left ITA was utilized and did not occur in any of the diabetic patients in whom the skeletonized left ITA was utilized. Post CABG surgery frequency of deep infection of the sternal wound was greater in those patients in whom the LITA was harvested utilizing the pedicled technique (p&lt;0.05). Conclusion: There is decreased frequency of deep infection of the sternal wound in patients with diabetes utilizing the skeletonized harvesting technique of the left ITA after CABG Surgery.

Negative-pressure sternal wound closure with interrupted subcuticular suturing and a subcutaneous drain tube reduces the incidence of poststernotomy wound infection after coronary artery bypass grafting surgery.

To retrospectively evaluate the effect of negative-pressure sternal wound closure (NPSWC) with a subcutaneous closed drain tube on the sternal surgical site infection (SSI) incidence. After propensity score matching of 231 patients undergoing coronary artery bypass grafting (CABG), we compared 104 pairs in the NPSWC and historical control groups. In the molecular analysis, the interleukin-6 (IL-6), basic fibroblast growth factor (b-FGF), and transforming growth factor β1 (TGF-β1) levels in the wound fluid were measured using two different reservoir types at postoperative days 2 and 7. NPSWC significantly reduced the SSI incidence from 10.6 to 2.9%. No mediastinitis occurred in the NPSWC group. A multivariate logistic regression analysis identified female sex (p = 0.0040) and no NPSWC (p = 0.0084) as significant risk factors for sternal SSI development. The Negative-pressure value was 49.4 ± 4.1 and 115.5 ± 15.2mmHg in the standard-type (SSR) and bulb-type suction reservoirs (BSR), respectively. Given that growth factors were affected by the difference in negative pressure, the IL-6, b-FGF, and TGF-β1 levels were significantly higher in the BSR than in the SSR. NPSWC using a subcutaneous closed drain tube was effective in preventing sternal SSI after CABG and may accelerate wound healing even when both internal thoracic arteries are harvested. University Hospital Medical Information Network Clinical Trials Registry, registration number: UMIN000037060.

INDIRECT CORONARY REIMPLANTATION IS ASSOCIATED WITH INCREASED OPERATIVE RISK IN PATIENTS UNDERGOING A BENTALL PROCEDURE AFTER PREVIOUS CARDIAC SURGERY

We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. From 1990 to 2014, 473 patients underwent a redo Bentall procedure with a composite valve graft (CVG) at a single institution (CVG with a mechanical prosthesis, n = 256; CVG with a bioprosthesis, n = 217). The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality (MMOM): stroke, renal failure, prolonged mechanical ventilation, deep sternal infection or reoperation during the same admission. Median age was 57 (IQR: 44 – 67) years and 349 (74%) patients were male. Median time between index surgery and reoperation was 13 (IQR: 8-21) years. One hundred seventy-eight (38%) patients underwent urgent or emergent intervention, 61 (13%) had active endocarditis, 87 (19%) had an LVEF < 40%, and 262 (55%) patients had undergone more than one previous operation. Previous surgery included CABG (n=58, 12%), aortic valve/root repair (n=36, 8%) or replacement (n=376, 80%), and other surgical interventions (n=245, 52%). Ninety-five (20%) patients had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 80 patients, a Ross operation in 8, a valve-sparing root replacement in 4, and an arterial switch in 3. At the time of the reoperative Bentall, both coronaries were reimplanted directly in 352 (74%) patients, whereas 72 (15%) patients received at least one interposition graft (saphenous vein in 42, and synthetic in 30). In 32 (7%) patients, at least one of the native coronary arteries was oversewn and a vein graft bypass performed. Thirty-day mortality occurred in 37 patients (7.8%) and 152 (32%) patients suffered MMOM. On multivariable analysis, risk factors associated with increased 30-day mortality included older age (OR per 5-year age increment [95% CI]: 1.20 [1.04-1.38], p = 0.01) and coronary reimplantation by a technique other than direct anastomosis (OR 3.71 [1.76-7.87], p < 0.001). Indirect coronary reimplantation was also associated with a higher incidence of MMOM (OR 1.71 [1.05-2.77], p=0.03), as were older age (OR per 5-year age increment: 1.08 [1.01-1.17], p = 0.03), preoperative NYHA functional class IV (OR 3.44 [1.55-7.62], p=0.002), and more than one previous cardiac operation (OR 1.75 [1.11-2.76], p=0.02). In the largest reported cohort of aortic root replacement after previous cardiac surgery, reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important predictor of adverse perioperative events.

Successful management of absent sternum in an infant using porcine acellular dermal matrix.

Congenital absent sternum is a rare birth defect that requires early intervention for optimal long-term outcomes. Descriptions of the repair of absent sternum are limited to case reports, and no preferred method for management has been described. Herein, we describe the use of porcine acellular dermal matrix to reconstruct the sternum of an infant with sternal infection following attempted repair using synthetic mesh. The patient was a full-term male with trisomy 21, agenesis of corpus callosum, ventricular septal defect, patent ductus arteriosus, right-sided aortic arch, and congenital absence of sternum with no sternal bars. Following removal of the infected synthetic mesh, negative pressure wound therapy with instillation was used to manage the open wound and provide direct antibiotic therapy. When blood Creactive protein levels declined to ≤2 mg/L, the sternum was reconstructed using porcine acellular dermal matrix. At 21 months postoperative, the patient demonstrated no respiratory issues. Physical examination and computed tomography imaging identified good approximation of the clavicular heads and sternal cleft and forward curvature of the ribs. This case illustrates the benefits of negative pressure wound therapy and acellular dermal matrix for the reconstruction of absent sternum in the context of infected sternal surgical site previously repaired with synthetic mesh.

Isolated primary cold abscess of the sternum: a case report

BackgroundMusculoskeletal tuberculosis forms 10–25% of extrapulmonary tuberculosis which mainly involves the spine or weight-bearing joints. Tuberculous involvement of the sternum is a rare clinical entity even in countries where tuberculosis has high prevalence. Primary tuberculous sternal osteomyelitis accounts for approximately 0.3% of all types of tubercular osteomyelitis and the probable source appears to be extension from paratracheal or hilar lymph nodes. Despite tuberculosis being a common disease in endemic countries and worldwide, a thorough literature search of the PubMed database for keywords “primary tuberculosis of sternum” and “primary tuberculous osteomyelitis of sternum” yielded 30 and 22 articles, respectively.Case presentationWe present an unusual case of a large dumb-bell-shaped cold abscess arising due to infection of the sternum. A 23-year-old immunocompetent Asian woman presented with a gradually progressing painless swelling on anterior chest wall for the last 5 months. She had a large visible swelling on anterior chest wall which was 12.5 cm in diameter, soft, non-tender, temperature was not raised, and fluctuant. Magnetic resonance imaging showed a large dumb-bell-shaped hyperintense collection in upper anterior chest wall with marrow edema and cortical irregularity in left side of manubrium. Pus was positive for nucleic acid testing (cartridge-based nucleic acid amplification test) for Mycobacterium tuberculosis and later culture was also positive. She was started on anti-tubercular therapy and aspirated twice. Currently, she has completed 6 months of therapy and the swelling has now disappeared.DiscussionSwelling, pain localized to sternum, or ulceration of the skin with discharging sinus along with or without constitutional symptoms are the usual presentation. A high element of suspicion is needed for early diagnosis and treatment to prevent its complications. Sternal mycobacterial infections are categorized as primary, secondary, and/or acquired postoperatively. Although radiological investigations aid in diagnosis, the diagnosis is established by positive culture or histopathological examination. Anti-tubercular therapy is the mainstay of treatment with standard four-drug regimen for 6–9 months. Surgical drainage of the abscess should be considered only if it does not resolve by aspiration and anti-tubercular therapy.

Helpful sternal wound vacuum‐assisted closure techniques in two open chest situations: Central extracorporeal membrane oxygenation and sternal infection

Dressing open sternal wounds after cardiac surgery can be challenging. In cases where extracorporeal membrane oxygenation (ECMO) is required, the sternum is left open with cannulae traversing the wound, making it difficult to create a water-tight seal and maintain sterility. Patients with a deep sternal infection may also be left with an open sternum between the time of debridement and reconstruction; in such cases, stabilizing the dressing in an ambulatory patient can pose a challenge. Two cases are reviewed, each highlighting the solutions to the problems mentioned above. In case 1, a patient with an open sternum and central ECMO, we describe construction of a dressing that achieves air seal and blood seal, and helps maintain the cannulae in a safe, stable position. In case 2, an ambulatory patient, we describe a modification of a recently published "Two Bridge Technique" that provides a stable dressing in three dimensions. Performance of specific techniques and attention to detail in complex situations can make a big difference in open sternum patients treated with temporary, vacuum-assisted dressings. Achieving vacuum and fluid seal is important for sterility, integrity of adjacent skin, and caregiver safety.

Re-pericardiectomy for recurrent chronic constrictive pericarditis: left anterolateral thoracotomy is a better approach

BackgroundPericardiectomy is the final treatment for constrictive pericarditis. However, this greatest surgical approach is still very controversial. This study pursued to assess the outcomes in patients with recurrent chronic constrictive pericarditis undergoing reoperated pericardiectomy via median sternotomy versus left anterolateral thoracotomy and to explain which surgical approaches might be better for recurrent chronic constrictive pericarditis.MethodsA total of 24 patients were identified with recurrent chronic constrictive pericarditis and underwent reoperation with pericardiectomy between July 2003 and July 2015. The decision for this surgical approach was mainly dependent on the operating surgeon’s preference. Out of 20 patients, 16 patients underwent pericardiectomy via median sternotomy and 8 patients via left anterolateral thoracotomy pericardiectomy. Their data were obtained retrospectively from the case notes.ResultsBoth groups of patients were similar in age, gender between two operations, and also in peripheral venous pressure, cardiac rhythm and New York Heart Association (NYHA) class distribution. The mortality rates were similar in both groups with one death (12.5%) due to low cardiac output syndrome in the left anterolateral thoracotomy group and two deaths (12.5%) in the median sternotomy group. All the deaths were associated with cardiac complications and happened in the perioperative period. NYHA functional class status enhanced in most of the patients. Patients in both groups had a similar and significant improvement in their NYHA status that improved from 3.4 ± 0.7 to 1.8 ± 0.1 (P = 0.001) in the left anterolateral thoracotomy group and reduced from 3.3 ± 0.6 to 1.9 ± 0.4 (P = 0.001) in the median sternotomy group. There was a significantly greater rate of pulmonary infection in the thoracotomy group than in the median sternotomy group (50% versus 25%, P = 0.02). Nevertheless, there was a significantly greater occurrence of wound infections in the median sternotomy group in 3 patients versus in one patient of the left anterolateral thoracotomy group (18.8% versus 12.5%, P = 0.02).ConclusionsLeft thoracotomy incision was preferred to sternotomy in the current setting of this situation and was done safely without CPB. It avoided life-threatening sternal infection and it also has showed an equal as well las significant enhancement of NYHA status of the patients.

Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies.

We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy. PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding. Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR withthe bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77). TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.

Unilateral Pedicled Pectoralis Major Harvested by Endoscopic-Assisted Method Achieves Adequate Management of Sternal Infection and Mediastinitis.

Bilateral PM muscles or combination with rectus abdominis or omentum are commonly used for upper and lower sternal wound infections. Unilateral PM harvesting using endoscopic-assisted method may have a simple, safe, and reliable entire muscle harvesting with comparable result of less donor-site violation. A retrospective review was performed from 2003 till 2015 on 38 patients referred to a single plastic surgeon for treatment of sternal wound infection following median sternotomy for cardiovascular surgery. After the humerus insertion of PM was cut with the assistance of endoscope visualization, all the other PM insertions on the sternum, rib, and clavicle were divided, the unilateral pedicled PM can be advanced approximately 10 cm to cover the cephalad and caudal sternum, and fill the retrosternal mediastinum. Four re-explorations in three patients for postoperative hematoma occurred. No early recurrent infection for wound dehiscence experienced. Three patients died of multiple organs failures as 30-day mortality. Two patients underwent late recurrent infections; one patient had twice wire infection removals at 4 and 6 months after transfer, and the other had another PM for rib osteomyelitis in 3 years. Unilateral PM transfer is justified to provide a simple, reliable, straightforward procedure for sternal infection management and mediastinal obliteration without violation of second flap in compromised patients.

Through Tricuspid Closure for Doubly Committed Subarterial Ventricular Septal Defect with Right Vertical Subaxillary Mini-incision: A Matched-Pair Analysis.

To evaluate the feasibility and efficacy of the right subaxillary vertical mini-incision (RAVI) used for the closure of doubly committed subarterial ventricular septal defect (SAVSD) through tricuspid approach only. From June 2015 to September 2016, 32 SAVSD patients (mean age 2.4 ± 1.9years, range 0.7-8years) underwent surgical repair with either RAVI (incision length 3-4cm) through tricuspid (group A, n = 16) or conventional median sternotomy incision through the main pulmonary artery approach (group B, n = 16). A retrospective 1:1 matched-pair analysis was performed with the group B matched for defect size, body weight, gender, patching, and operation year. The demographic characteristics in both groups were similar. No patient died and only 1 patient in group B needed reoperation for sternal infection. The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 48.6 ± 12.6min, 29.3 ± 8.5min in the group A and 57.8 ± 14.1min (p = 0.03), 34.3 ± 12.1min ( p = 0.18) in the group B. There was no significant difference between the two groups in the ICU stay (17.8 ± 8.9h in group A, 18.7 ± 9.5h in group B, p = 0.79), mechanical ventilation support time (2.7 ± 1.7h in group A, 3.6 ± 1.5h in group B, p = 0.11), postoperative hospital stay (6.3 ± 1.5days in group A, 7.4 ± 1.7days in group B, p = 0.06), and chest tube drainage (6.4 ± 4.3ml/kg in group A, 8.5 ± 3.8ml/kg in group B, p = 0.16). No significant residual defects were found in both groups. The post-operation pressure gradient across the right ventricular outflow tract (RVOT) was significantly different between the two groups with 4.6 ± 1.8mmHg in group A and 10.0 ± 6.8mmHg in group B (p = 0.004) even if no significant difference was found between both groups before operation. No arrhythmia was found after operation. All the patients or the parents (100%) in the group A were satisfied with the cosmetic results, while the number in B group was 7 (43.8%) in questionnaire. The RAVI through tricuspid approach to repair doubly committed subarterial ventricular septal defect is a safe and feasible procedure with better hemodynamic performance of RVOT and less CPB time because of keeping pulmonary artery intact comparing to conventional approach. More importantly, the RAVI through tricuspid approach can be performed with favorable cosmetic results.

Impact of blood transfusion on major infection after isolated coronary artery bypass surgery: Incidence and risk factors

Background/aimCardiac surgery is considered one of the conditions that require a transfusion of blood and blood products in large amount. Infections are one of the most common complications after cardiac surgery. The aim of this study is to assess the impact of blood transfusion on major infections after isolated coronary artery bypass surgery (CABG). MethodsA retrospective cohort study was conducted at King Abdulaziz Cardiac Center. Eligible adult patients, aged >18 years, who underwent an isolated CABG from 2015 to 2016, were included. Patient demographic information, as well as pre-, intra-, and postoperative data were collected from the electronic hospital information system charts and perfusion records. For data analysis, categorical pre- and postoperative variables were summarized by frequencies and percentages, whereas for continuous variables, means and standard deviation or median and interquartile ranges were used. ResultsThe sample size was 459 patients. Red blood cells (RBCs) were transfused in 60.1% of the patients, and the median number of units transfused per patient was 2. The mean hemoglobin threshold for transfusion was 8.2 (standard deviation ± 3.6) g/dL. The mean EuroSCORE of RBC recipients was 3.8 ± 5.9% and that of non-RBC recipients was 2.0 ± 2.0%. In both groups (RBC recipients and non-RBC recipients), the most frequent infections after CABG were pneumonia (12% and 8.7%, respectively), deep surgical site infection (3.6% and 0.5%, respectively), and superficial sternal infection (6.9% and 3.8%, respectively), with a statistically significant difference (all p < 0.05). Patients receiving a blood transfusion at any stage during the intraoperative or postoperative period were 2.6 times more likely to develop an infection compared with those who did not receive a blood transfusion. The recipients of a blood transfusion experienced a longer hospital stay compared with the non-recipients at 11.5 ± 9.8 days versus 8.7 ± 3.4 days, respectively. ConclusionsBlood transfusion appears to increase the risk of infection post-CABG. However, increased understanding of the role of other potential clinical confounding variables that may impact the infection rate is required. We recommend management strategies that limit RBC transfusion.

Professional Society Leadership in Health Care Quality: The Society of Thoracic Surgeons Experience

The STS quality program is overseen by the STS Council on Quality, Research, and Patient Safety, which has four components. The Workforce on Research Development, in collaboration with the STS Research Center, coordinates clinical research based on the STS National Database, all of which is focused on improving clinical outcomes. The Workforce on Evidence Based Surgery develops clinical practice guidelines and expert consensus documents to foster the use of best practices. The Workforce on Patient Safety disseminates high-reliability practices from within and outside health care to improve the safety of cardiothoracic surgical care. The Workforce on National Databases consists of four subspecialty registries (adult cardiac, congenital cardiac, general thoracic, mechanical circulatory support [Intermacs and Pedimacs]) and multiple functionally oriented task forces (Quality Measurement, Quality Initiatives, Public Reporting, Informatics, Patient-Reported Outcomes, and Aortic Surgery). Between 1998 and 2016, the rates of coronary artery bypass grafting surgery adverse outcomes decreased substantially, including operative mortality (-31.3%), renal failure (-56.3%), stroke (-43.5%), reoperation (-65.7%), and sternal infection (-50.0%). Comparable increases in process measure compliance included internal mammary artery use (32%), preoperative beta-blocker use (83.1%), discharge antiplatelet drugs (22.9%), discharge antilipid drugs (78.6%), and discharge beta-blockers (54.1%). The STS quality program has achieved remarkable, continuing improvements in patient safety and quality over several decades. The components of this program can be replicated by other health care professional societies to advance quality and safety for their patient populations.

Aortic root surgery with the CARDIOROOT vascular graft: results of a prospective multicenter post-market surveillance study

BackgroundSparing Aortic Valve procedure requires to reproduction of the geometry of the physiologic anatomy of the aortic root. Thus, the materials adopted may make a difference. CARDIOROOT is a one-piece collagen-coated woven vascular graft with pseudo-sinuses, which was designed for use in the treatment of aortic root disease. We report the results of a prospective, multicenter, observational post-market surveillance study evaluating the safety and performance of the CARDIOROOT in patients requiring aortic root surgery.MethodsPatients with aortic root disease suitable for treatment with a vascular graft with pseudo-sinuses CARDIOROOT graft were eligible for participation. The enrolled patients were assessed intraoperatively, post-operatively, at discharge and at 1-year. Sites assessed complications at each visit, and recorded any reported adverse events. The study endpoint was mortality and complications through 1-year post-procedure.ResultsFifty-two patients were enrolled from 6 European centers. All procedures were technically successful. Operative mortality was 1.9%: one patient suffered hemorrhagic shock unrelated to the graft 1 day following surgery. At 1-year follow-up the survival rate was 96.2%, with a late death due to pneumonia 5 months post-procedure. Eleven serious adverse events occurred in 7 patients, which included cardiac complications (pericardial effusion, myocardial infarction and ventricular arrhythmia), infection (pericardial infection, deep sternal infection and superficial sternal infection), vascular disorders, including hemorrhagic shock and pleural effusion requiring drainage. Nine of the 11 events were deemed procedure-related by the local investigator, and all were deemed unrelated to the device. There were no reports of graft-related adverse events, infection, occlusion or graft failure.ConclusionsThe results of this 1-year follow-up study showed that the CARDIOROOT vascular graft is safe and effective for the treatment of aneurysmal aortic root in immediate and mid-term follow-up. However, longer term follow-up is needed before conclusions can be made on the long-term safety and effectiveness.Trial registrationClinicalTrials.gov Identifier: NCT01609270. Registered 31 May 2012.

Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps.

The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

Rigid Primary Sternal Fixation Reduces Sternal Complications Among Patients at Risk

The optimal sternal closure technique in patients at elevated risk after cardiac surgery has not been elucidated. Between January 2006 and July 2015, 15,048 consecutive adult patients underwent cardiac surgery via median sternotomy using cardiopulmonary bypass. Rigid sternal fixation using 3 separate techniques (peristernal polyether ether-ketone banding, titanium plating, and stainless steel multibraided cables with cannulated screws) was used in 1111 patients (group A), whereas conventional peristernal/transsternal wiring was used in 13,937 patients (group B). Predictors of deep sternal wound infection or dehiscence were evaluated, and propensity score analysis was used to create 2 matched groups; 1050 group A patients (94.5%) were matched to group B patients. Mean time to presentation was 31 ± 70.3 days (median, 19) after surgery. There was a decreased incidence of deep sternal wound infection or dehiscence among propensity score-matched group A compared with group B patients (1.9% vs 2.7%, P= .13), although it was not statistically significant. On multivariate analysis, group A was associated with a 33% relative risk reduction of deep sternal wound infection or dehiscence (odds ratio, 0.67; 95% confidence interval, 0.48-0.94; P= .02); this was entirely due to a protective effect associated with polyether ether-ketone banding (odds ratio, 0.4; 95% confidence interval, 0.3-0.7; P= .0002). In the subgroup of bilateral internal mammary artery grafting patients (n= 886), there was a strong protective trend associated with preventative sternal fixation, although it was not statistically significant (odds ratio, 0.3; 95% confidence interval, 0.09-1.09; P= .06). Primary sternal fixation in patients at risk of sternal complications is associated with decreased sternal infection and/or dehiscence. Primary fixation may expand the use of bilateral internal mammary artery grafting to patient populations at increased risk for sternal complications.

Cost-Effectiveness of Negative Pressure Incision Management System in Cardiac Surgery

BackgroundSternal wound infections (SWIs) can be a devastating long-term complication with significant morbidity and health care cost. The purpose of this analysis was to evaluate the cost-effectiveness of negative pressure incision management systems (NPIMS) in cardiac surgery. Materials and methodsAll cardiac surgery cases at an academic hospital with risk scores available (2009-2017) were extracted from an institutional database (n = 4455). Patients were stratified by utilization of NPIMS, and high risk was defined as above the median. Costs included infection-related readmissions and were adjusted for inflation. Multivariable regression models assessed the risk-adjusted cost of SWI and efficacy of NPIMS use. Cost-effectiveness was modeled using TreeAge Pro using institutional results. ResultsThe rate of deep SWI was 0.9% with an estimated cost of $111,175 (P < 0.0001). The rate of superficial SWI was 0.8% at a cost of $7981 (P = 0.08). Risk-adjusted NPIMS use was not significantly associated with reduced SWI (OR 1.2, P = 0.62) and thus not cost-effective. However, in the high-risk cohort with an OR 0.84 (P = 0.72) and SWI rate of 2.3%, NPIMS use cost $205 per patient with an incremental cost-effectiveness ratio of $179,092. Therefore, NPIMS is estimated to be cost-effective with a deep SWI rate over 1.3% or improved efficacy (OR < 0.83). ConclusionsSWIs are extremely expensive complications with estimates of $111,175 for deep yet only $7981 for superficial. Although NPIMS was not cost-effective for SWI prevention as currently utilized, a protocol for use on patients with a higher risk of sternal infection could be cost-effective.

Are two internal thoracic grafts better than one? An analysis of 5301 cases.

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease. Patients in our institution who underwent BITA grafting during 1996-2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan-Meier analysis was performed, both for the entire cohort and for the matched cohort. SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan-Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001). Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization.