|
1
|
Khashkhusha A, Butt S, Abdelghaffar M, Wang W, Rajananthanan A, Roy S, Khurshid BN, Zeinah M, Harky A. Sternal Wound Reconstruction Following Deep Sternal Wound Infection: Past, Present and Future: A Literature Review. J Cardiovasc Dev Dis 2024; 11:361. [PMID: 39590204 PMCID: PMC11595137 DOI: 10.3390/jcdd11110361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Revised: 10/24/2024] [Accepted: 10/28/2024] [Indexed: 11/28/2024] Open
Abstract
This literature review critically examines the historical, current, and prospective dimensions of sternal wound reconstruction in the specific context of deep sternal wound infection (DSWI), aiming to enhance patient outcomes and optimise surgical techniques. Preventive measures, including prophylactic antibiotic administration and surgical site preparation, are crucial in reducing the incidence of DSWI. Effective management necessitates a multidisciplinary approach encompassing surgical debridement, drainage, and sternum repair utilising diverse procedures in conjunction with antibiotic therapy. Traditional approaches to managing DSWI involved closed irrigation and drainage techniques. While these methods exhibited certain advantages, they also exhibited limitations and varying degrees of success. The current care paradigms emphasise prophylactic antibiotic administration and surgical interventions like closed suction and irrigation, vacuum-assisted closure, and flap reconstruction. Future advancements in surgical techniques and technology hold promise for further enhancing sternal wound reconstruction. This review separates and emphasises the distinct roles of prophylaxis, antibiotic treatment, and reconstructive techniques, each relevant specifically to DSWI management. Collaborative efforts between cardiac and plastic surgeons, supported by ongoing research and innovation, are indispensable to advance sternal wound restoration and achieve superior outcomes in terms of patient welfare, morbidity and mortality reduction, and surgical efficacy.
Collapse
Affiliation(s)
- Arwa Khashkhusha
- School of Medicine, Faculty of Health and Life Science, University of Liverpool, Liverpool L3 5TR, UK
| | - Sundas Butt
- Department of Plastic Surgery, Nottingham City Hospital, Nottingham NG5 1PB, UK
| | - Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Building No. 2441, Road 2835, Busaiteen 228, Muharraq P.O. Box 15503, Bahrain
| | - William Wang
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AD, UK
| | | | - Sakshi Roy
- School of Medicine, Queen’s University Belfast, Belfast BT9 7BL, UK
| | - Bakht Noor Khurshid
- Department of Medicine, University Medical & Dental College (UMDC), Sargodha Rd, University Town, Faisalabad 38000, Punjab, Pakistan
| | - Mohamed Zeinah
- Faculty of Medicine, Ain Sham University, Cairo 11566, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| |
Collapse
|
|
2
|
Chen Y, He F, Wu F, Hu X, Zhang W, Li S, Zhang H, Duan W, Guan H. Developing a calculable risk prediction model for sternal wound infection after median sternotomy: a retrospective study. BURNS & TRAUMA 2024; 12:tkae031. [PMID: 39282020 PMCID: PMC11401447 DOI: 10.1093/burnst/tkae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/25/2024] [Indexed: 09/18/2024]
Abstract
Background Diagnosing sternal wound infection (SWI) following median sternotomy remains laborious and troublesome, resulting in high mortality rates and great harm to patients. Early intervention and prevention are critical and challenging. This study aimed to develop a simple risk prediction model to identify high-risk populations of SWI and to guide examination programs and intervention strategies. Methods A retrospective analysis was conducted on the clinical data obtained from 6715 patients who underwent median sternotomy between January 2016 and December 2020. The least absolute shrink and selection operator (LASSO) regression method selected the optimal subset of predictors, and multivariate logistic regression helped screen the significant factors. The nomogram model was built based on all significant factors. Area under the curve (AUC), calibration curve and decision curve analysis (DCA) were used to assess the model's performance. Results LASSO regression analysis selected an optimal subset containing nine predictors that were all statistically significant in multivariate logistic regression analysis. Independent risk factors of SWI included female [odds ratio (OR) = 3.405, 95% confidence interval (CI) = 2.535-4.573], chronic obstructive pulmonary disease (OR = 4.679, 95% CI = 2.916-7.508), drinking (OR = 2.025, 95% CI = 1.437-2.855), smoking (OR = 7.059, 95% CI = 5.034-9.898), re-operation (OR = 3.235, 95% CI = 1.087-9.623), heart failure (OR = 1.555, 95% CI = 1.200-2.016) and repeated endotracheal intubation (OR = 1.975, 95% CI = 1.405-2.774). Protective factors included bone wax (OR = 0.674, 95% CI = 0.538-0.843) and chest physiotherapy (OR = 0.446, 95% CI = 0.248-0.802). The AUC of the nomogram was 0.770 (95% CI = 0.745-0.795) with relatively good sensitivity (0.798) and accuracy (0.620), exhibiting moderately good discernment. The model also showed an excellent fitting degree on the calibration curve. Finally, the DCA presented a remarkable net benefit. Conclusions A visual and convenient nomogram-based risk calculator built on disease-associated predictors might help clinicians with the early identification of high-risk patients of SWI and timely intervention.
Collapse
Affiliation(s)
- Yang Chen
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Fei He
- School of Public Management, Northwest University, Xi'an, 710127, Shaanxi, People's Republic of China
| | - Fan Wu
- Department of Cardiovascular Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Xiaolong Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Wanfu Zhang
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Shaohui Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Hao Zhang
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Hao Guan
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| |
Collapse
|
|
3
|
Ernert C, Kielstein H, Azatyan A, Prantl L, Kehrer A. Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification. Clin Hemorheol Microcirc 2024; 86:225-236. [PMID: 37742631 DOI: 10.3233/ch-238115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. OBJECTIVE This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). METHODS Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). RESULTS Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). CONCLUSIONS By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.
Collapse
Affiliation(s)
- Carsten Ernert
- Department of Plastic, Hand and Microsurgery, Ev. Waldkrankenhaus Spandau, Berlin, Germany
| | - Heike Kielstein
- Institute of Anatomy, Martin Luther University Halle Wittenberg, Halle, Germany
| | - Argine Azatyan
- Department of Plastic, Reconstructive and Breast Surgery, Görlitz Hospital, Görlitz, Germany
| | - Lukas Prantl
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
- Division of Hand and Plastic Surgery, Ingolstadt Hospital, Ingolstadt, Germany
| |
Collapse
|
|
4
|
Farhoud N, Farhoud H, Deutsch JM. Primary Cardiac Lymphoma in a Young and Immunocompetent Patient Diagnosed by Percutaneous Transvenous Biopsy. Am J Cardiol 2023; 201:139-141. [PMID: 37385165 DOI: 10.1016/j.amjcard.2023.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/21/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023]
Abstract
Primary cardiac lymphoma is a rare cardiac neoplasm that is typically found in older, immunocompromised patients. In this case, we report an immunocompetent, 46-year-old female that presented with shortness of breath and chest discomfort. Diagnosis of primary cardiac lymphoma was confirmed by way of percutaneous transvenous biopsy under transesophageal echocardiography and cardiac fluoroscopy guidance.
Collapse
Affiliation(s)
- Noor Farhoud
- University of Kansas School of Medicine, Wichita, Kansas.
| | - Hassan Farhoud
- University of Kansas School of Medicine, Wichita, Kansas
| | - Jeremy M Deutsch
- Internal Medicine Department, University of Kansas School of Medicine, Wichita, Kansas
| |
Collapse
|
|
5
|
Hu QL, Ko CY. Prevention of Perioperative Surgical Site Infection. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
|
|
6
|
Abstract
PURPOSE OF REVIEW Poststernotomy mediastinitis (PSM) remains a serious infection and is significantly associated with high morbidity, short-term and long-term mortality. Gram-negative bacteria (GNB) are an underestimated cause of PSM, and there is little information on the risk factors, prevention, diagnosis and management of GNB PSM. RECENT FINDINGS The pathogenesis of PSM is the result of a complex and multifactorial interplay between intraoperative wound contamination, host-related and surgical host factors but GNB are probably mostly translocated from other host site infections. GNB are frequent cause of PSM (18-38% of cases) and GNB PSM have shown to more frequently polymicrobial (20-44%). GNG PSM has shown to occur earlier than Gram-positive PSM. Early diagnosis is crucial to successful treatment. The management of PSM needs a combination of culture-directed antimicrobial therapy and an early extensive surgical debridement with either immediate or delayed closure of the sternal space. Antibiotic treatment choice and duration should be based on clinical evaluation, evolution of inflammatory markers, microbiological tests and imaging studies. Mortality has shown to be significantly higher with GNB PSM compared with other causes and the inappropriateness of initial antibiotic therapy may explain the worse outcome of GNB PSM. SUMMARY GNB PSM is usually undervalued in the setting of PSM and have shown to be a frequent cause of inappropriate treatment with adverse prognostic potential. There is a need for efforts to improve knowledge to prevent and adequately treat GNB PSM.
Collapse
|
|
7
|
Wang L, Ji Q, Hu X. Role of targeted and universal mupirocin-based decolonization for preventing surgical-site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis. Exp Ther Med 2021; 21:416. [PMID: 33747157 PMCID: PMC7967856 DOI: 10.3892/etm.2021.9860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 11/29/2022] Open
Abstract
The purpose of the present study was to provide a systematic literature review and pool evidence on the efficacy of mupirocin-based decolonization protocol in reducing surgical-site infections (SSIs) in patients undergoing cardiothoracic (CT) surgery based on their Staphylococcus (S.) aureus carrier state. The PubMed, Embase, Ovid, BioMed Central, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched for studies comparing mupirocin-based decolonization with controls for reducing SSIs in patients following CT surgery. Studies were grouped based on the targeted population of intervention, i.e. carriers or all patients. A total of 17 studies were included. Of these, 8 studies used targeted mupirocin-based decolonization, while universal decolonization was performed in 9 studies. The results were conflicting for studies performing targeted decolonization and it was not possible to perform a meta-analysis due to non-homogenous studies. Pooled analysis of 34,859 patients indicated that universal mupirocin-based decolonization significantly reduced the risk of all SSIs [risk ratio (RR): 0.54; 95% CI: 0.40,0.75; I2=73.35%]. The intervention significantly reduced the risk of superficial SSIs (RR: 0.37; 95% CI: 0.25,0.55; I2=0%) but not of deep SSIs (RR: 0.45; 95% CI: 0.19,1.09; I2=80.67%). The results indicated a significantly reduced risk of S. aureus SSIs (SA-SSIs) with mupirocin-based decolonization (RR: 0.44; 95% CI: 0.32,0.61; I2=0%) but not for methicillin-resistant S. aureus (MRSA-SSIs; RR: 0.25; 95% CI: 0.05,1.28; I2=79.07%). Evidence on the role of targeted mupirocin-based decolonization to reduce SSIs after CT surgery was non-coherent and inconclusive. Analysis of low-quality retrospective studies suggested that universal mupirocin-based decolonization may reduce all SSIs, superficial SSIs and SA-SSIs, but not deep SSIs or MRSA-SSIs in patients after CT surgery.
Collapse
Affiliation(s)
- Li Wang
- Departments of Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
| | - Qi Ji
- Departments of Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
| | - Xiaoyan Hu
- Departments of Tongguan Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
| |
Collapse
|
|
8
|
Majid FM, Buba FM, Barry M, Alsharani F, Alfawzan F. Incidence, types and outcomes of sternal wound infections after cardiac surgery in Saudi Arabia. A retrospective medical chart review. Saudi Med J 2021; 41:177-182. [PMID: 32020152 PMCID: PMC7841641 DOI: 10.15537/smj.2020.2.24843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives: To determine the incidence, types, risk factors, identify organisms, and assess outcomes of surgical wound infections (SWIs) after cardiac surgery at a tertiary hospital in Riyadh, Saudi Arabia. Methods: This historical cohort study reviewed the chart of patients who underwent cardiac surgery at King Khalid University Hospital, Riyadh, Saudi Arabia between January 2009 and December 2014. The proforma contained personal data, comorbidities, type of surgery, microbiological analysis, and management outcomes. Results: A total of 1241 patients were enrolled in the study comprising 1,032 (83.2%) men and 209 (16.8%) women. Forty (3.2%) patients developed SWI, of which 32 (2.5%) were superficial and 8 (0.7%) were deep. Gender, obesity, diabetes mellitus, non-use of statins, and coronary artery bypass graft (CABG) surgery were not significant predictors of infection in the study. Methicillin-susceptible Staphylococcus aureus was isolated predominantly in 45%, followed by Klebsiella and Pseudomonas species. Methicillin-resistant Staphylococcus aureus, Enterococcus faecium, and extended β-lactamase-producing gram-negative organisms were pathogens isolated in last 3 years of the review. Simple and vacuum assisted closure therapies led to complete resolution in 32 (80%) patients, while 8 (20%) developed sternal osteomyelitis. All patients survived except one with a deep SWI who died of uncontrolled sepsis. Conclusion: Despite the low incidence of postoperative SWIs, the risk of sternal osteomyelitis development persists. Meticulous choice of CABG components and appropriate postoperative management, especially detecting early signs of SWI could contribute to lower its incidence and complications.
Collapse
Affiliation(s)
- Fahad M Majid
- Department of Infectious Diseases, King Saudi University, Riyadh, Kingdom of Saudi Arabia. E-mail.
| | | | | | | | | |
Collapse
|
|
9
|
Ravikumar N, George V, Shirke MM, Ashry A, Harky A. Robotic coronary artery surgery: Outcomes and pitfalls. J Card Surg 2020; 35:3108-3115. [DOI: 10.1111/jocs.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Nidhruv Ravikumar
- Department of Medicine, School of Medicine Queen's University Belfast Belfast UK
| | - Varghese George
- Department of Medicine, School of Medicine Queen's University Belfast Belfast UK
| | - Manasi M. Shirke
- Department of Medicine, School of Medicine Queen's University Belfast Belfast UK
| | - Amr Ashry
- Department of Cardiothoracic Surgery Liverpool Heart and Chest Liverpool UK
- Department of Cardiothoracic Surgery Assiut University Hospital Assiut Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery Liverpool Heart and Chest Liverpool UK
- Department of Integrative Biology, Faculty of Life Sciences University of Liverpool Liverpool UK
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart and Chest Hospital Liverpool UK
| |
Collapse
|
|
10
|
Wojnarski CM, Elgudin Y, Rubelowsky JJ, Wilson BM, Donskey CJ, Cmolik BL. Emerging trends in mediastinitis: National Veterans Health Administration experience with methicillin-resistant Staphylococcus aureus prevention. J Thorac Cardiovasc Surg 2020; 162:1125-1130.e1. [PMID: 32386766 DOI: 10.1016/j.jtcvs.2020.02.116] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Perioperative bacterial decolonization and prophylactic antibiotic therapy at the Veterans Affairs Health Care System have changed over the past decade. Our objectives were to identify associated changes in the microbiology of mediastinitis and to perform a contemporary survival analysis in patients with mediastinitis after isolated coronary artery bypass grafting procedure. METHODS From January 2006 to December 2015, 45,323 consecutive patients underwent coronary artery bypass grafting at 83 medical centers. The Veterans Affairs Health Care System nationwide administrative database was queried to identify patients with postoperative mediastinitis and obtain patient-level data. Simple descriptive statistics and multivariable logistic regression were used to analyze microbiologic data and identify risk factors for infection. Poisson regression was used to determine yearly incidence estimates. Cox proportional hazard model identified predictors of long-term survival from date of operation. RESULTS During the study period, 348 patients (0.78%) developed postoperative mediastinitis-with a stable rate of incidence (Cochrane-Armitage test, P = .69). Of patients with microbiologic data, 75.5% of infections (n = 188) were caused by gram-positive and 24.5% (n = 61) gram-negative organisms. The incidence of methicillin-resistant Staphylococcus aureus mediastinitis decreased during the study period (Cochrane-Armitage test, P = .013). Gram-negative mediastinitis occurred earlier than gram-positive mediastinitis (median, 15.0 vs 25.0 days; P < .0001). Patients with mediastinitis did not have increased 30-day mortality (2.0% vs 1.9%; P = .9), but had worse long-term survival compared with uninfected patients (P < .0001). CONCLUSIONS The incidence of methicillin-resistant S aureus mediastinitis has decreased over the past decade. Gram-negative bacteria are responsible for 1 in 4 cases of mediastinitis and infection is diagnosed earlier in the postoperative period than gram-positive mediastinitis. These findings highlight the need for efforts to prevent gram-negative and methicillin-susceptible S aureus mediastinitis.
Collapse
Affiliation(s)
- Charles M Wojnarski
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC.
| | - Yakov Elgudin
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Joseph J Rubelowsky
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; Infectious Diseases Section, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Brian L Cmolik
- Department of Cardiothoracic Surgery, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| |
Collapse
|
|
11
|
Abdelnoor M, Sandven I, Vengen Ø, Risnes I. Mediastinitis in open heart surgery: a systematic review and meta-analysis of risk factors. SCAND CARDIOVASC J 2019; 53:226-234. [PMID: 31290699 DOI: 10.1080/14017431.2019.1642508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 06/18/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
Objective. We aimed to summarize the evidence from observational studies examining the risk factors of the incidence of mediastinitis in open heart surgery. Design. The study was a systematic review and meta-analysis of cohorts and case-control studies. Material and methods. We searched the literature and 74 studies with at least one risk factor were identified. Both fixed and random effects models were used. Heterogeneity between studies was examined by subgroup and meta-regression analysis. Publication bias or small study effects were evaluated and corrected by limit meta-analysis. Results. When correcting for small study effect, presence of obesity as estimated from 43 studies had Odds Ratio OR = 2.26. (95% CI: 2.17-2.36). This risk was increasing with decreasing latitude of study place. Presence of diabetes mellitus from 63 studies carried an OR = 1.90 (95% CI: 1.59-2.27). Presence of Chronic Obstructive Pulmonary Disease (COPD) from 30 studies had an OR = 2.59 (95% CI: 2.22-2.85). Presence of bilateral intramammary graft (BIMA) from 23 studies carried an OR = 2.54 (95% CI: 2.07-3.13). This risk was increasing with increasing frequency of female patients in the study population. Conclusion. Evidence from this study showed the robustness of the risk factors in the pathogenesis of mediastinitis. Preventive measures can be implemented for reducing obesity, especially in lower latitude countries. Furthermore, it is mandatory to monitor perioperative hyperglycemias with continuous insulin infusion. Use of skeletonized BIMA carries higher risk of mediastinitis especially in female patients without evidence of beneficial effect on survival for the time being.
Collapse
Affiliation(s)
- Michael Abdelnoor
- Centre of Clinical Heart Research, Oslo University Hospital , Oslo , Norway
- Epidemiology and Biological Statistics, Independent Health Research Unit , Oslo , Norway
| | - Irene Sandven
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital , Oslo , Norway
| | - Øystein Vengen
- Department of Cardiovascular Surgery, Oslo University Hospital , Oslo , Norway
| | - Ivar Risnes
- Department of Cardiovascular Surgery, Oslo University Hospital , Oslo , Norway
- Department of Cardiovascular Surgery, LHL Hospital , Gardemoen , Norway
| |
Collapse
|
|
12
|
Lonský V, Dominik J, Manďák J, Pozlerová E, Hejzlar M, Lonská V, Maršíková M, Kubíček J, Snítilová M. Changes of the Serum Antibiotic Levels During Open Heart Surgery (ceftazidim, ciprofloxacin, clindamycin). ACTA MEDICA (HRADEC KRÁLOVÉ) 2019. [DOI: 10.14712/18059694.2019.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Wound, mediastinal and intracardiac infections are still very serious complications of open-heart surgey. The incidence of it is still in the range of 0.4%-5%. The aims of our study were to assess the adequacy of regimen using ceftazidim (CTZ), ciprofloxacin (CPF) and clindamycin (CLIN) as prophylactic antibiotics and to verify whether cardiopulmonary bypass (CPB) can modify the time of antibiotic serum concentrations. That is why the serum levels of them were measured during open heart procedures. Methods: The prospective study comprised 75 consequent coronary patients randomized in to three groups receiving 1 g of CTZ or 400 mg of CPF or 900 mg of CLIN i.v. with anesthesia induction. Routine coronary surgery with left internal mammary artery harvesting, moderate body hypothermic (30 °C) CPB with crystaloid cardioplegia was performed. Serum antibiotic levels were determined before application, with skin incision, prior CPB induction, after cardioplegia infusion, every 20 minutes of CPB, prior end of CPB, in time of chest closure. Conventional cylinder – plate microbiological assay was used for antibiotic levelmeasurement. Results: All serum antibiotic concentrations showed a sharp decrease immediately after starting CPB and lasted until CPB ended. After initiating of CPB after cardioplegia administration serum concentrations of CTZ (105 min after initial dose) decreased by, on average 55%, CPF (97 min) by 42% and CLIN (116 min) by 78%. Conclusion: CPB can modify the time course of antibiotic serum concentrations. The serum levels of CTZ at the end of the longest procedures were found to be below the MICs for some of the suspected pathogens. We recommend to use higher antibiotic doses for prophylaxis and to administer the second dose with protamin sulphate to obtain maximum concentration in newly formed blood clots.
Collapse
|
|
13
|
Barbera F, Lorenzetti F, Marsili R, Lisa A, Guido G, Pantaloni M. The Impact of Preoperative Negative-Pressure Wound Therapy on Pectoralis Major Muscle Flap Reconstruction for Deep Sternal Wound Infections. Ann Plast Surg 2019; 83:195-200. [DOI: 10.1097/sap.0000000000001799] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
|
14
|
Stastny L, Kofler M, Dumfarth J, Basaran A, Wiedemann D, Schachner T, Feuchtner G, Bonatti J, Bonaros N. Long-Term Clinical and Computed Tomography Angiographic Follow-up After Totally Endoscopic Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:5-10. [PMID: 29465628 DOI: 10.1097/imi.0000000000000461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Totally endoscopic coronary artery bypass grafting was shown to be feasible and safe, with excellent clinical and angiographic mid-term results. Data on long-term outcome are lacking. Therefore, we aimed to investigate the long-term rate of major adverse cardiac and cerebrovascular events and left internal mammary artery patency rate in patients undergoing arrested heart totally endoscopic coronary artery bypass grafting. METHODS From 2001 to 2012, a total of 208 arrested heart-totally endoscopic coronary artery bypass grafting patients were prospectively included. Mean ± SD age was 58.8 ± 9.4 years, and mean ± SD Society of Thoracic Surgeons score was 0.5 ± 0.5%. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, stroke, re-percutaneous coronary intervention, re-coronary artery bypass graft, and target vessel revascularization. Left internal mammary artery patency was assessed using cardiac computed tomography and depicted according to the established Fitzgibbon classification. Mean ± SD follow-up was 6.9 ± 2.3 years. RESULTS At 1, 5, and 10 years, survival rate was 100%, 98.3%, and 95.8%, respectively. The freedom from clinical events at 1, 5, and 10 years were major adverse cardiac and cerebrovascular events (93.5%, 85.9%, and 83.0%), myocardial infarction (99.0%, 97.4%, and 95.9%), target vessel revascularization (96.0%, 94.3%, and 91.7%), re-percutaneous coronary intervention (94.5%, 91.6%, and 84.2%), and re-coronary artery bypass graft (100%, 99.5%, and 99.5%), respectively. Left internal mammary artery patency rate at 1, 5, and 10 years was 100%, 94.9%, and 88.1%, respectively. CONCLUSIONS Arrested heart-totally endoscopic coronary artery bypass grafting shows excellent clinical long-term results with a left internal mammary artery patency rate comparable with conventional coronary artery bypass graft at 10 years after surgery.
Collapse
|
|
15
|
Rashed A, Verzar Z, Alotti N, Gombocz K. Xiphoid-sparing midline sternotomy reduces wound infection risk after coronary bypass surgery. J Thorac Dis 2018; 10:3568-3574. [PMID: 30069354 DOI: 10.21037/jtd.2018.06.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Because of its advantages, full midline sternotomy has remained the main approach for cardiac surgery. However, the development of post-sternotomy wound infections is its primary disadvantage. We evaluated the impact of xiphoid process (XIP)-sparing midline sternotomy regarding reducing the risk of deep sternal wound infections (DSWIs). Methods Data from 446 patients who underwent coronary artery bypass grafting by one surgeon, from January 2007 through May 2017, were retrospectively analyzed. Patients were divided into preliminary (from 2007-2011; n=202) and contemporary (January 2012-May 2017; n=244) groups. Traditional midline sternotomy was performed in the preliminary group, while xiphoid-sparing midline sternotomy was performed in the contemporary group. To adjust for differences in baseline and operative characteristics, the inverse probability of treatment weighting (IPTW) was applied. The generalized linear model was used to compare xiphoid-sparing and conventional sternotomy regarding the development of sternal wound infections. Results The sternal infection rates were 0.8% and 4.5% in the xiphoid-sparing and standard sternotomy groups, respectively (P=0.014). After adjustment for the IPTW, the xiphoid-sparing group showed a decreased risk for DSWIs (odds ratio 0.171, 95% confidence interval, 0.036-0.806, P=0.026) compared to the traditional sternotomy group. Conclusions XIP-sparing midline sternotomy may be an alternative approach in coronary artery bypass surgery and seemed to reduce the risk of post-sternotomy wound infections in this study.
Collapse
Affiliation(s)
- Aref Rashed
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Zsofia Verzar
- Department of Emergency Medicine, Pecs University of Science, Pecs, Hungary
| | - Nasri Alotti
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Karoly Gombocz
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| |
Collapse
|
|
16
|
Lednev PV, Belov YV, Stonogin AV, Lysenko AV, Salagaev GI. [Postoperative sternomediastinitis]. Khirurgiia (Mosk) 2018:84-89. [PMID: 29697690 DOI: 10.17116/hirurgia2018484-89] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- P V Lednev
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - Yu V Belov
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Stonogin
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Lysenko
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - G I Salagaev
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| |
Collapse
|
|
17
|
Stastny L, Kofler M, Dumfarth J, Basaran A, Wiedemann D, Schachner T, Feuchtner G, Bonatti J, Bonaros N. Long-Term Clinical and Computed Tomography Angiographic Follow-Up after Totally Endoscopic Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lukas Stastny
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Kofler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alim Basaran
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schachner
- Department of Cardiac Surgery, Kepler University Linz, Linz, Austria
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Bonatti
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
|
18
|
Extensively Drug-Resistant Pseudomonas aeruginosa Sternal Osteomyelitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
|
19
|
Lo Torto F, Monfrecola A, Kaciulyte J, Ciudad P, Casella D, Ribuffo D, Carlesimo B. Preliminary result with incisional negative pressure wound therapy and pectoralis major muscle flap for median sternotomy wound infection in a high-risk patient population. Int Wound J 2017; 14:1335-1339. [PMID: 28901717 DOI: 10.1111/iwj.12808] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/22/2017] [Indexed: 01/14/2023] Open
Abstract
Deep sternal wound infection (DSWI) represents a dangerous complication that can follow open-heart surgery with median sternotomy access. Muscle flaps, such as monolateral pectoralis major muscle flap (MPMF), represent the main choices for sternal wound coverage and infection control. Negative pressure incision management system has proven to be able to reduce the incidence of these wounds' complications. Prevena™ represents one of these incision management systems and we aimed to evaluate its benefits. A total of 78 patients with major risk factors that presented post-sternotomy DSWI following cardiac surgery was selected. Thrity patients were treated with MPMF and Prevena™ (study group). Control group consisted of 48 patients treated with MPMF and conventional wound dressings. During the follow-up period, 4 (13%) adverse events occurred in the study group, whereas 18 complications occurred (37·5%) in the control group. Surgical revision necessity and mean postoperative time spent in the intensive care unit were both higher in the control group. Our results evidenced Prevena™ system's ability in improving the outcome of DSWI surgical treatment with MPMF in a high-risk patient population.
Collapse
Affiliation(s)
- Federico Lo Torto
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| | - Ambra Monfrecola
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| | - Juste Kaciulyte
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| | - Pedro Ciudad
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Donato Casella
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| | - Diego Ribuffo
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| | - Bruno Carlesimo
- Department of Surgery 'P.Valdoni,' Unit of Plastic and Reconstructive Surgery, 'Sapienza' University of Rome, Rome, Italy
| |
Collapse
|
|
20
|
Spindler N, Etz CD, Misfeld M, Josten C, Mohr FW, Langer S. Omentum flap as a salvage procedure in deep sternal wound infection. Ther Clin Risk Manag 2017; 13:1077-1083. [PMID: 28883736 PMCID: PMC5574694 DOI: 10.2147/tcrm.s134869] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures. METHODS We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded. RESULTS Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome. DISCUSSION The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.
Collapse
Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| |
Collapse
|
|
21
|
Affiliation(s)
- Siew S.C. Goh
- Department of Cardiothoracic Surgery; Liverpool Hospital; NSW Australia
| |
Collapse
|
|
22
|
Case-Control Study of Risk Factors for Mediastinitis After Cardiovascular Surgery. Infect Control Hosp Epidemiol 2017. [DOI: 10.1017/s0195941700075366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report results of a case-control study in which we evaluated 41 risk factors potentially associated with the development of post-surgical mediastinitis. There were 163 case patients and 326 control patients. Independent risk factors kept in the final multivariate logistic regression model were obesity (defined as a body mass index of greater than 30), diabetes mellitus, chronic obstructive pulmonary disease, preoperative stay longer than 1 week, pulmonary hypertension, perioperative myocardial infarction, and reoperation.
Collapse
|
|
23
|
Basu SK, Bain J, Chattopadhyay D, Majumdar BK. Extensive Chest Wall Tissue Loss and its Management by Vertical Rectus Abdominis Myocutaneous Flap. J Indian Assoc Pediatr Surg 2017; 22:43-45. [PMID: 28082777 PMCID: PMC5217140 DOI: 10.4103/0971-9261.194621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Extensive electric burn around the chest in children is rare and this type of injury always poses a great challenge for its management. A 12-year-old male child with extensive electric burn of the chest wall was admitted to hospital. It was a neglected case of 9 days old burn; the young boy was in critical condition having systemic features of toxemia with widespread necrosis of the skin, subcutaneous tissues, and muscles along with exposed bones (ribs and sternum) with the risk of impending rupture of pleura through the exposed intercostal spaces. After initial resuscitation, a thorough debridement of all necrotic tissues was done. Thereafter, a superiorly based vertical rectus abdominis myocutaneous flap was harvested to cover the exposed bones and intercostal spaces. The remaining raw areas were skin grafted. The child made an excellent recovery with good outcome.
Collapse
Affiliation(s)
- Sandip Kanti Basu
- Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Jayanta Bain
- Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Debarati Chattopadhyay
- Department of Plastic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Bijay Kumar Majumdar
- Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| |
Collapse
|
|
24
|
Abstract
A new technique for reinforced sternal closure is described. The method consists of placing longitudinal in-and-out wires, on each side of the sternum. The 2 longitudinal wires, which lie within the standard transverse wires, are joined and tightened at the upper and lower parts of the sternum after approximation of the transverse wires. This technique was found to be quick, simple and extremely effective.
Collapse
Affiliation(s)
- Khalid Al-Ebrahim
- Department of Cardiac Surgery Alhada Armed Forces Hospital Taif, Saudi Arabia
| | - Hussein Shafei
- Department of Cardiac Surgery Alhada Armed Forces Hospital Taif, Saudi Arabia
| |
Collapse
|
|
25
|
Balachandran S, Lee A, Denehy L, Lin KY, Royse A, Royse C, El-Ansary D. Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review. Ann Thorac Surg 2016; 102:2109-2117. [DOI: 10.1016/j.athoracsur.2016.05.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/27/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
|
|
26
|
Sabzi F, Yaghoubi A. The combination of breast necrosis and chylothorax following the OPCAB. J Cardiovasc Thorac Res 2016; 8:88-90. [PMID: 27493707 PMCID: PMC4972404 DOI: 10.15171/jcvtr.2016.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 05/06/2016] [Indexed: 11/23/2022] Open
Abstract
Due to long term patency, the internal mammary artery is considered as a conduit of choice for revascularization of the left anterior descending coronary artery. The internal mammary artery and its accessory branches in addition to perfusing the chest wall structures also contributes to supplying, part of the female breast arteries. In addition, due to the accompaniment of thoracic duct branches with the left internal mammary artery, harvesting may be associated with injury to these branches and contribute to chylothorax. We report a rare case of chylothorax and the breast necrosis following the coronary artery bypass grafting. The chylothorax was started in the second postoperative day and ceased gradually in the 12th day of operation. The breast necrosis appeared in the 3th weeks of operation with pain, and tenderness and black skin color change. The patient underwent total mastectomy in the 4th weeks of operation.
Collapse
Affiliation(s)
- Feridoun Sabzi
- Department of Cardiovascular Surgery, Imam Ali Heart Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Yaghoubi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
|
27
|
Deng Y, Byth K, Paterson HS. Semi-Skeletonized Internal Mammary Artery Grafts and Sternal Wound Complications. Asian Cardiovasc Thorac Ann 2016; 12:227-32. [PMID: 15353461 DOI: 10.1177/021849230401200310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aimed to evaluate the risk factors for sternal wound complications in patients undergoing myocardial revascularization using bilateral semi-skeletonized internal mammary arteries. Prospectively collected data on 751 patients undergoing coronary artery surgery from September 1994 to August 2002 were analyzed. The mean age of the patients was 56 years, 633 (84%) were male, 44 (6%) were over 66 years of age, and 170 (23%) were diabetic. Forty-four (5.9%) patients developed sternal wound complications. Among these cases, sternal infection occurred in 22 (2.9%) patients, of which 15 (2.0%) had sternal infection with mediastinitis and 7 (0.9%) had sternal infection alone. Independent risk factors for any sternal wound complications were peripheral vascular disease, diet-controlled diabetes, and delayed sternal closure. The risk factors for sternal infection were diabetes, postoperative pulmonary complications, and postoperative stroke. The perioperative mortality rate was 1.5% (11 patients), including 2 patients who had sternal wound complications. The use of bilateral semi-skeletonized internal mammary artery conduits carries a comparable sternal wound complication rate as conduits harvested by other techniques.
Collapse
Affiliation(s)
- Yongzhi Deng
- Department of Cardiothoracic Surgery, Westmead Hospital, Australia
| | | | | |
Collapse
|
|
28
|
López Gude MJ, San Juan R, Aguado JM, Maroto L, López-Medrano F, Cortina Romero JM, Rufilanchas JJ. Case-Control Study of Risk Factors for Mediastinitis After Cardiovascular Surgery. Infect Control Hosp Epidemiol 2016; 27:1397-400. [PMID: 17152041 DOI: 10.1086/509854] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 04/12/2006] [Indexed: 11/03/2022]
Abstract
We report results of a case-control study in which we evaluated 41 risk factors potentially associated with the development of post-surgical mediastinitis. There were 163 case patients and 326 control patients. Independent risk factors kept in the final multivariate logistic regression model were obesity (defined as a body mass index of greater than 30), diabetes mellitus, chronic obstructive pulmonary disease, preoperative stay longer than 1 week, pulmonary hypertension, perioperative myocardial infarction, and reoperation.
Collapse
Affiliation(s)
- M J López Gude
- Department of Cardiothoracic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | | | | | | |
Collapse
|
|
29
|
Abdelnoor M, Vengen ØA, Johansen O, Sandven I, Abdelnoor AM. Latitude of the study place and age of the patient are associated with incidence of mediastinitis and microbiology in open-heart surgery: a systematic review and meta-analysis. Clin Epidemiol 2016; 8:151-163. [PMID: 27330329 PMCID: PMC4898030 DOI: 10.2147/clep.s96107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We aimed to summarize the pooled frequency of mediastinitis following open-heart surgery caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria. DESIGN This study was a systematic review and a meta-analysis of prospective and retrospective cohort studies. MATERIALS AND METHODS We searched the literature, and a total of 97 cohort studies were identified. Random-effect model was used to synthesize the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses, considering study and patient-level variables. Small-study effect was evaluated. RESULTS Substantial heterogeneity was present. The estimated incidence of mediastinitis evaluated from 97 studies was 1.58% (95% confidence intervals [CI] 1.42, 1.75) and that of Gram-positive bacteria, Gram-negative bacteria, and MRSA bacteria evaluated from 63 studies was 0.90% (95% CI 0.81, 1.21), 0.24% (95% CI 0.18, 0.32), and 0.08% (95% CI 0.05, 0.12), respectively. A meta-regression pinpointed negative association between the frequency of mediastinitis and latitude of study place and positive association between the frequency of mediastinitis and the age of the patient at operation. Multivariate meta-regression showed that prospective cohort design and age of the patients and latitude of study place together or in combination accounted for 17% of heterogeneity for end point frequency of mediastinitis, 16.3% for Gram-positive bacteria, 14.7% for Gram-negative bacteria, and 23.3% for MRSA bacteria. CONCLUSION Evidence from this study suggests the importance of latitude of study place and advanced age as risk factors of mediastinitis. Latitude is a marker of thermally regulated bacterial virulence and other local surgical practice. There is concern of increasing risk of mediastinitis and of MRSA in elderly patients undergoing sternotomy.
Collapse
Affiliation(s)
- M Abdelnoor
- Centre for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Ø A Vengen
- Department of Cardiovascular Surgery, Oslo University Hospital, Oslo, Norway
| | - O Johansen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - I Sandven
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - AM Abdelnoor
- Department of Experimental Pathology, Immunology and Microbiology, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
|
30
|
Abstract
Musculoskeletal infections caused by Staphylococcus aureus are among the most difficult-to-treat infections. S. aureus osteomyelitis is associated with a tremendous disease burden through potential for long-term relapses and functional deficits. Although considerable advances have been achieved in diagnosis and treatment of osteomyelitis, the management remains challenging and impact on quality of life is still enormous. S. aureus acute arthritis is relatively seldom in general population, but the incidence is considerably higher in patients with predisposing conditions, particularly those with rheumatoid arthritis. Rapidly destructive course with high mortality and disability rates makes urgent diagnosis and treatment of acute arthritis essential. S. aureus pyomyositis is a common disease in tropical countries, but it is very seldom in temperate regions. Nevertheless, the cases have been increasingly reported also in non-tropical countries, and the physicians should be able to timely recognize this uncommon condition and initiate appropriate treatment. The optimal management of S. aureus-associated musculoskeletal infections requires a strong interdisciplinary collaboration between all involved specialists.
Collapse
|
|
31
|
Barnea Y, Lerner A, Aizic A, Navon-Venezia S, Rachi E, Dunne MW, Puttagunta S, Carmeli Y. Efficacy of dalbavancin in the treatment of MRSA rat sternal osteomyelitis with mediastinitis. J Antimicrob Chemother 2015; 71:460-3. [DOI: 10.1093/jac/dkv357] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/01/2015] [Indexed: 11/13/2022] Open
|
|
32
|
Reser D, Caliskan E, Tolboom H, Guidotti A, Maisano F. Median sternotomy. Multimed Man Cardiothorac Surg 2015; 2015:mmv017. [PMID: 26188337 DOI: 10.1093/mmcts/mmv017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/25/2015] [Indexed: 11/12/2022]
Abstract
Sternotomy is considered to be the gold standard incision in cardiac surgery, resulting in low failure rates and excellent proven long-term outcomes. It can also be used in thoracic surgery for mediastinal, bilateral pulmonary or lower trachea and main stem bronchus surgery. Sternotomy has to be performed properly to avoid short- and long-term morbidity and mortality. The surgical technique is well established and certain principles are recognized to be crucial to minimize complications. The identification of the correct landmarks, midline tissue preparation, osteotomy with the avoidance of injury to underlying structures like pleura, pericardium, innominate vein, brachiocephalic artery and ectatic ascending aorta, and targeted bleeding control are important steps of the procedure. As important as the performance of a proper sternotomy is a correct sternal closure. An override or shift of the sternal edges has to be avoided by placing the wires at a proper distance from each other without injuring the thoracic pedicle. The two sternal halves have to be tightly re-approximated to facilitate healing of the bone and to avoid instability, which is a risk factor for wound infection. With a proper performance of sternotomy and sternal closure, instability and wound infections are rare and depend on patient-related risk factors.
Collapse
Affiliation(s)
- Diana Reser
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Etem Caliskan
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Herman Tolboom
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Andrea Guidotti
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| |
Collapse
|
|
33
|
Motomatsu Y, Imasaka KI, Tayama E, Tomita Y. Midterm Results of Sternal Band Closure in Open Heart Surgery and Risk Analysis of Sternal Band Removal. Artif Organs 2015; 40:153-8. [DOI: 10.1111/aor.12514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Yuma Motomatsu
- Department of Cardiovascular Surgery; Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Ken-ichi Imasaka
- Department of Cardiovascular Surgery; Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Eiki Tayama
- Department of Cardiovascular Surgery; Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Yukihiro Tomita
- Department of Cardiovascular Surgery; Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| |
Collapse
|
|
34
|
Case report of a rare complication of open-heart surgery masquerading as a gunshot wound: an autopsy diagnosis. Am J Forensic Med Pathol 2015; 36:66-70. [PMID: 25828033 DOI: 10.1097/paf.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). Poststernotomy mediastinitis can in uncommon instances give rise to sternocutaneous fistulas in 0.25% to 10% of cases. Although scant reports have documented prosthetic valve endocarditis occurring in a setting of deep sternal wire infections, it is an infrequent but well-documented fatal complication of valvular replacement surgery. CASE REPORT A 52-year-old male smoker with aortic valve replacement (2011), on Coumadin and Monocor, was found dead on September 2013 with a hole along a surgical scar over the sternum, masquerading as a gunshot wound. Chest radiograph revealed no foreign body, and no evidence of homicidal/suicidal or accidental cause was found at autopsy. Examination revealed a chronic fistulous tract from a deep sternal wire infection to the skin, in addition to a chronic sinus tract eroding into the root of the aorta with recent prosthetic valve endocarditis. DISCUSSION To our knowledge, this is the first case report documenting poststernotomy mediastinitis causing a simultaneous occurrence of sternocutaneous fistula and prosthetic valve endocarditis. Either of these 2 exceptional but lethal complications would have sufficed as the cause of death.
Collapse
|
|
35
|
Sajja LR. Strategies to reduce deep sternal wound infection after bilateral internal mammary artery grafting. Int J Surg 2015; 16:171-8. [DOI: 10.1016/j.ijsu.2014.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/10/2014] [Accepted: 11/11/2014] [Indexed: 01/04/2023]
|
|
36
|
Bejko J, Bottio T, Tarzia V, De Franceschi M, Bianco R, Gallo M, Castoro M, Bortolussi G, Gerosa G. Nitinol flexigrip sternal closure system and standard sternal steel wiring. J Cardiovasc Med (Hagerstown) 2015; 16:134-8. [DOI: 10.2459/jcm.0000000000000025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
|
37
|
Lemaire A, Dombrovskiy V, Batsides G, Scholz P, Solina A, Brownstone N, Spotnitz A, Lee LY. The effect of Clostridium difficile infection on cardiac surgery outcomes. Surg Infect (Larchmt) 2014; 16:24-8. [PMID: 25402213 DOI: 10.1089/sur.2013.097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clostridium difficile (CD) is a common cause of healthcare-associated infectious colitis that complicates about 1% of all hospital stays in the U.S. The impact of CD on outcomes after coronary artery bypass grafting (CABG) and valvular surgery (VS) is not well known. METHODS The Nationwide Inpatient Sample (2002-2009) was queried to identify CABG and VS patients utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Rates of CD, post-operative endocarditis and mediastinitis, hospital mortality rate, and resource utilization were evaluated. RESULTS We identified 421,294 and 90,923 patients of age 40 yrs and older who underwent CABG and VS, respectively. The CD infection was more likely to develop in patients undergoing VS than in those having CABG (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.64-1.92) and was more likely after urgent or emergency admission than after elective admission (OR 1.8; 95% CI 1.68-1.94). There was a greater likelihood of mediastinitis in patients with CD after CABG than in non-complicated cases without CD, both by univariable (OR 6.0; 95% CI 3.07-11.62) and multivariable analysis with adjustment for patient age, gender, race, type of admission, and co-morbidities (OR 3.1; 95% CI 1.49-6.51). The infection thus was most likely a result of the antibiotics used to treat mediastinitis, as the patients treated for mediastinitis were most likely to develop CD. There was a significant association in patients with CD and endocarditis who underwent VS but not in patients who did not have CD. The CD infection in these patients thus was most likely a result of the antibiotics used to treat endocarditis. Endocarditis and CD developed 3.2 times (95% CI 2.65-3.97) as often as in patients without CD, a finding that was confirmed by multivariable analysis (OR 2.2; 95% CI 1.70-2.84). At the same time, in patients having VS, there was no significant association of CD and mediastinitis. Clostridium difficile infection affected the hospital mortality rate significantly after both CABG (OR 2.0; 95% CI 1.65-2.35) and VS (OR 1.9; 95% CI 1.51-2.39). Development of CD increased median hospital length of stay and cost dramatically after both CABG (from 7 d to 19 d and from $33,105 to $65,535, respectively; p<0.0001 for both) and VS (from 8 d to 24 d and from $41,876 to $95,699, respectively; p<0.0001 for both). CONCLUSIONS The development of CD worsened significantly the outcomes of adult patients undergoing cardiac surgery. There was a greater risk of CD in patients with either mediastinitis or endocarditis. The infection was associated with a higher hospital mortality rate, longer hospital stays, and greater cost after both CABG and VS.
Collapse
Affiliation(s)
- Anthony Lemaire
- Department of Surgery, UMDNJ-Robert Wood Johnson University Hospital , New Brunswick, New Jersey
| | | | | | | | | | | | | | | |
Collapse
|
|
38
|
LaPar DJ, Isbell JM, Mulloy DP, Stone ML, Kern JA, Ailawadi G, Kron IL. Planned cardiac reexploration in the intensive care unit is a safe procedure. Ann Thorac Surg 2014; 98:1645-51; discussion 1651-2. [PMID: 25173720 DOI: 10.1016/j.athoracsur.2014.05.090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/25/2014] [Accepted: 05/29/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cardiac surgical reexploration is necessary in approximately 5% of all patients. However, the impact of routine, planned reexploration performed in the intensive care unit (ICU) remains poorly defined. This study evaluated postoperative outcomes after cardiac reexplorations to determine the safety and efficacy of a planned approach in the ICU. METHODS All patients undergoing ICU cardiac reexplorations (2000 to2011) at a single institution were stratified according to a routine, planned ICU approach to reexploration (planned) versus unplanned ICU or operating room reexploration. Patient risk and outcomes were compared by univariate and multivariate analyses. RESULTS 8,151 total patients underwent cardiac operations, including 267 (3.2%) reexplorations (planned ICU=75% and unplanned ICU=18%). Among planned ICU reexplorations, 38% of patients had an identifiable surgical bleeding source, and 60% underwent reexploration less than 12 hours after the index procedure. Unplanned ICU reexplorations had a higher Society of Thoracic Surgeons (STS) predicted mortality (5% vs 3%, p<0.001) and incurred higher observed mortality (37% vs 6%, p<0.001) and morbidity. Sternal wound infections were rare and were similar between groups (p=0.81). Furthermore, upon STS mortality risk adjustment, unplanned ICU reexplorations were associated with significantly increased odds of mortality (OR=26.6 [7.1, 99.7], p<0.001) compared with planned ICU reexplorations. CONCLUSIONS Planned reexploration in the ICU is a safe procedure with acceptable mortality and morbidity and low infection rates. Unplanned reexplorations, however, increase postoperative risk and are associated with high mortality and morbidity. These data argue for coordinated, routine approaches to planned ICU reexploration to avoid delay in treatment for postoperative hemorrhage.
Collapse
Affiliation(s)
- Damien J LaPar
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - James M Isbell
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel P Mulloy
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Matthew L Stone
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - John A Kern
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Irving L Kron
- The Virginia Interdisciplinary Cardiothoracic Outcomes Research (VICTOR) Center, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
| |
Collapse
|
|
39
|
Comparison of force exerted on the sternum during a sneeze versus during low-, moderate-, and high-intensity bench press resistance exercise with and without the valsalva maneuver in healthy volunteers. Am J Cardiol 2014; 113:1045-8. [PMID: 24440333 DOI: 10.1016/j.amjcard.2013.11.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/21/2022]
Abstract
Sternal precautions are intended to prevent complications after median sternotomy, but little data exist to support the consensus recommendations. To better characterize the forces on the sternum that can occur during everyday events, we conducted a prospective nonrandomized study of 41 healthy volunteers that evaluated the force exerted during bench press resistance exercise and while sneezing. A balloon-tipped esophageal catheter, inserted through the subject's nose and advanced into the thoracic cavity, was used to measure the intrathoracic pressure differential during the study activities. After the 1 repetition maximum (1-RM) was assessed, the subject performed the bench press at the following intensities, first with controlled breathing and then with the Valsalva maneuver: 40% of 1-RM (low), 70% of 1-RM (moderate), and 1-RM (high). Next, various nasal irritants were used to induce a sneeze. The forces on the sternum were calculated according to a cylindrical model, and a 2-tailed paired t test was used to compare the mean force exerted during a sneeze with the mean force exerted during each of the 6 bench press exercises. No statistically significant difference was found between the mean force from a sneeze (41.0 kg) and the mean total force exerted during moderate-intensity bench press exercise with breathing (41.4 kg). In conclusion, current guidelines and recommendations limit patient activity after a median sternotomy. Because these patients can repeatedly withstand a sneeze, our study indicates that they can withstand the forces from more strenuous activities than are currently allowed.
Collapse
|
|
40
|
Kamiyoshihara M, Ibe T, Igai H, Kawatani N, Hayashi H, Shimizu K, Takeyoshi I. Profuse mediastinal hemorrhage due to mediastinitis after a sternal infection. Ann Thorac Cardiovasc Surg 2013; 20 Suppl:629-31. [PMID: 23995346 DOI: 10.5761/atcs.cr.13-00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 79-year-old female patient was admitted because of profuse bleeding from a skin defect in the anterior chest due to a deep sternal wound infection. Eighteen years earlier, she had undergone irradiation to treat a sternal metastasis from breast cancer. Computed tomography (CT) showed the extravasation of iodinated contrast material from the ascending aorta. The patient underwent an immediate thoracotomy and recovered. This report presents a very rare case of massive bleeding from the thoracic aorta due to a mediastinal infection after irradiation for sternal metastasis from breast cancer.
Collapse
|
|
41
|
Poststernotomy mediastinitis and the role of broken steel wires: retrospective study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:219-24. [PMID: 23989817 DOI: 10.1097/imi.0b013e3182a20e3c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mediastinitis is a severe complication of cardiac surgery. Sternal instability is concomitantly present in most cases. Broken steel wires may cause sternal instability. In this study, the role of broken steel wires in sternal closure was evaluated in patients who developed poststernotomy mediastinitis. METHODS Preoperative, perioperative, and postoperative data of patients who underwent thoracic surgery between 1996 and 2006 were retrieved from the SUMMIT registry database. Patients needing reoperation for mediastinitis were identified. Patients' charts and chest radiographs from initial surgery to reoperation for mediastinitis were reviewed. RESULTS Forty-five patients developed postoperative mediastinitis needing reoperation (0.6%). Because of loss to follow-up, 31 patients were evaluated. Eight patients (25.8%) presented fractured steel wires. Most of the broken steel wires (87.5%) manifested at the cranial site of figure-of-eight configurations. In the patients without broken steel wires, mediastinitis manifested after 14 days compared with 38 days in the patients with broken wires. Time until mediastinitis was not significantly different (P = 0.229). The mean time until steel wire disruption was 14 days (range, 4-48 days). CONCLUSIONS Broken steel wires were observed before mediastinitis became manifest. Fracturing occurred mainly at the cranial site of figure-of-eight configurations. The results of the present study emphasize that closure technique plays a prominent role in the development of mediastinitis. Because mediastinitis is associated with an increased risk for early morbidity, attention should be paid to patients presenting with broken steel wires. New techniques for median sternotomy closure are needed that are less prone to mechanical fatigue than are steel wires.
Collapse
|
|
42
|
Küçükdurmaz F, Ağır İ, Bezer M. Comparison of straight median sternotomy and interlocking sternotomy with respect to biomechanical stability. World J Orthop 2013; 4:134-138. [PMID: 23878782 PMCID: PMC3717247 DOI: 10.5312/wjo.v4.i3.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/15/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To increase the stability of sternotomy and so decrease the complications because of instability.
METHODS: Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costal joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-steel wiring. Fatigue testing was performed in cranio-caudal, anterio-posterior (AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s (0.2 Hz). The amount of displacement in AP, lateral and cranio-caudal directions were measured and also the opposing bone surface at the osteotomy areas were calculated at the two halves of sternum.
RESULTS: The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P < 0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P < 0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P > 0.001. The mean surface area was 10.40 ± 0.49 cm² for median sternotomy and was 16.8 ± 0.78 cm² for interlocking sternotomy, P < 0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.
CONCLUSION: Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.
Collapse
|
|
43
|
Meeks MD, Lozekoot PW, Verstraeten SE, Nelis M, Maessen JG. Poststernotomy Mediastinitis and the Role of Broken Steel Wires: Retrospective Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michelle D.M.E. Meeks
- Department of Cardiothoracic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Pieter W.J. Lozekoot
- Department of Cardiothoracic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Stefan E. Verstraeten
- Department of Cardiothoracic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | | | - Jos G. Maessen
- Department of Cardiothoracic Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| |
Collapse
|
|
44
|
An alternative technique for surgical management of poststernotomy osteomyelitis and reconstruction of the sternal defect. Case Rep Surg 2013; 2013:451594. [PMID: 23533913 PMCID: PMC3603623 DOI: 10.1155/2013/451594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/07/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction.
Sternal osteomyelitis with or without mediastinal infection is a severe and rare complication of median sternotomy. In this paper, an alternative technique for the reconstruction of sternal defects with the use of bilateral pectoralis major pedicled muscle flaps is presented. Case presentation. A 70-year-old man with the diagnosis of poststernotomy osteomyelitis underwent reconstruction of his sternal defect with the use of bilateral pectoralis major muscle flaps. The patient had an uneventful recovery, and the physical examination revealed a normal range of motion for both upper limbs and sternal stability. Conclusion. The proposed technique incorporates a simple mobilization of the two pectoralis major muscles to be used as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. Using this technique, a muscular implant is made that seals the dead space, which has no tension due to the presence of a second layer. Postoperative results are excellent, not only regarding infection and functionality but also from an aesthetic point of view.
Collapse
|
|
45
|
The association between hemoglobin A1C values and deep sternal wound infections in diabetes patients undergoing cardiac surgery. Cardiovasc Endocrinol 2013. [DOI: 10.1097/xce.0b013e32835eca16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|
|
46
|
Bejko J, Tarzia V, De Franceschi M, Bianco R, Castoro M, Bottio T, Gerosa G. Nitinol Flexigrip Sternal Closure System and Chest Wound Infections: Insight From a Comparative Analysis of Complications and Costs. Ann Thorac Surg 2012; 94:1848-53. [DOI: 10.1016/j.athoracsur.2012.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 08/04/2012] [Accepted: 08/10/2012] [Indexed: 11/25/2022]
|
|
47
|
Abstract
BACKGROUND Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined. MATERIALS AND METHODS A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay. RESULTS Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay. CONCLUSIONS Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.
Collapse
|
|
48
|
Grauhan O, Navasardyan A, Hofmann M, Müller P, Stein J, Hetzer R. Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. J Thorac Cardiovasc Surg 2012; 145:1387-92. [PMID: 23111014 DOI: 10.1016/j.jtcvs.2012.09.040] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 08/16/2012] [Accepted: 09/13/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The majority of wound infections after median sternotomy in obese patients are triggered by the breakdown of skin sutures and subsequent seepage of skin flora. The purpose of this study was to evaluate negative pressure wound dressing treatment for the prevention of infection. We hypothesized that negative pressure wound dressing treatment for 6 to 7 days applied immediately after skin closure reduces the numbers of wound infections. METHODS In a prospective study, 150 consecutive obese patients (body mass index ≥ 30) with cardiac surgery performed via median sternotomy were analyzed. In the negative pressure wound dressing treatment group (n = 75), a foam dressing (Prevena, KCI, Wiesbaden, Germany) was placed immediately after skin suturing, and negative pressure of -125 mm Hg was applied for 6 to 7 days. In the control group (n = 75), conventional wound dressings were used. The primary end point was wound infection within 90 days. Mann-Whitney U test and Fisher exact test were used. Freedom from infection was estimated by Kaplan-Meier analysis. RESULTS Three of 75 patients (4%) with continuous negative pressure wound dressing treatment had wound infections compared with 12 of 75 patients (16%) with conventional sterile wound dressing (P = .0266; odds ratio, 4.57; 95% confidence interval, 1.23-16.94). Wound infections with Gram-positive skin flora were found in only 1 patient in the negative pressure wound dressing treatment group compared with 10 patients in the control group (P = .0090; odds ratio, 11.39; 95% confidence interval, 1.42-91.36). CONCLUSIONS Negative pressure wound dressing treatment over clean, closed incisions for the first 6 to 7 postoperative days significantly reduces the incidence of wound infection after median sternotomy in a high-risk group of obese patients.
Collapse
Affiliation(s)
- Onnen Grauhan
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
| | | | | | | | | | | |
Collapse
|
|
49
|
Singh K, Anderson E, Harper JG. Overview and management of sternal wound infection. Semin Plast Surg 2012; 25:25-33. [PMID: 22294940 DOI: 10.1055/s-0031-1275168] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality. Past treatment options have included closed suction and continuous irrigation. Current paradigms in the management of sternal wound infection include surgical debridement, vacuum-assisted closure therapy, flap coverage, and sternal plating. We provide a general overview of sternal wound infection and treatment options for the plastic surgeon.
Collapse
Affiliation(s)
- Kimberly Singh
- Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Georgia
| | | | | |
Collapse
|
|
50
|
Netscher DT, Izaddoost S, Sandvall B. Complications, pitfalls, and outcomes after chest wall reconstruction. Semin Plast Surg 2012; 25:86-97. [PMID: 22294947 DOI: 10.1055/s-0031-1275175] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chest wall and mediastinal wounds may be life-threatening. Although modern reconstruction methods with various muscle flaps have reduced morbidity and mortality, chest wall reconstruction presents unique challenges. Major categories of adverse outcomes include (1) persistent infection; (2) interference with respiratory mechanics; (3) functional deficits of the shoulder; and (4) hernias. Persistent infection may be resolved by providing coverage via muscle or omental flap, performing thorough debridement, filling the "dead space" with adequate volume, buttressing repair of visceral fistulae, and covering exposed prosthetic material with vascularized flaps. Potential deficits in respiratory mechanics and shoulder function may be avoided by stabilizing the chest wall skeleton and decreasing donor muscle functional loss. Hernias may be minimized by maintaining visceral "right of domain" to the chest and abdominal cavities. Complex reconstructive cases represent an intricate interplay of physiology, structural protection, and aesthetic considerations and require integration of several management principles.
Collapse
Affiliation(s)
- David T Netscher
- Department of Orthopedic Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | | | | |
Collapse
|