Risk Factors For Sternal Breakdown in Cardiac Surgery Patients

European Journal of Cardio-Thoracic Surgery, 2008

Objective: To assess the impact of deep sternal wound infection on in-hospital mortality and mid-term survival following adult cardiac surgery. Methods: Prospectively collected data on 4586 consecutive patients who underwent a cardiac surgical procedure via a median sternotomy from 1st January 2001 to 31st December 2005 were analysed. Patients with a deep sternal wound infection (DSWI) were identified in accordance with the Centres for Disease Control and Prevention guidelines. Nineteen variables (patient-related, operative and postoperative) were analysed. Logistic regression analysis was used to calculate a propensity score for each patient. Late survival data were obtained from the UK Central Cardiac Audit Database. Mean follow-up of DSWI patients was 2.28 years. Results: DSWI requiring revision surgery developed in 1.65% (76/4586) patients. Stepwise multivariable logistic regression analysis identified age, diabetes, a smoking history and ventilation time as independent predictors of a DSWI. DSWI patients were more likely to develop renal failure, require reventilation and a tracheostomy postoperatively. Treatment included vacuum assisted closure therapy in 81.5% (62/76) patients and sternectomy with musculocutaneous flap reconstruction in 35.5% (27/76) patients. In-hospital mortality was 9.2% (7/76) in DSWI patients and 3.7% (167/4510) in non-DSWI patients (OR 1.300 (0.434-3.894) p = 0.639). Survival with Cox regression analysis with mean propensity score (co-variate) showed freedom from all-cause mortality in DSWI at 1, 2, 3 and 4 years was 91%, 89%, 84% and 79%, respectively compared with 95%, 93%, 90% and 86%, respectively for patients without DSWI ((p = 0.082) HR 1.59 95% CI (0.94-2.68)). Conclusion: DSWI is not an independent predictor of a higher in-hospital mortality or reduced mid-term survival following cardiac surgery in this population.

European Journal of Cardio-Thoracic Surgery, 2003

Objective: To identify risk factors for sternal wound infection following coronary artery bypass surgery (CABG), and to compare early and mid-term survival outcome. Methods: Data were prospectively collected for 4228 patients who underwent CABG surgery between April 1997 and March 2001. One hundred and nine (2.6%) patients developed sternal wound infection. We used logistic regression to identify independent risk factors associated with post-operative sternal wound infection. Patient records were linked to the National Strategic Tracing Service, which records all deaths in the UK, to establish current vital status. Deaths occurring over time were described using Kaplan-Meier techniques. To control for differences in patient characteristics, we used Cox proportional hazards analysis to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: The results of the logistic regression analysis found that the independent predictors of sternal wound infection were obesity (odds ratio (OR) 2.0; P , 0:001), New York Heart Association class $ 3 (OR 1.6; P ¼ 0:022), use of bilateral internal mammary arteries (OR 3.2; P , 0:001), increasing number of grafts (OR 1.5; P , 0:001), re-exploration for bleeding (OR 3.1; P ¼ 0:011), and increased duration of mechanical ventilation (for every 10 h (OR 1.12; P , 0:001)). Three hundred and forty one (8.1%) deaths occurred during the study period with mean follow up of 3.2^1.3 years. The crude HR of mid-term mortality for sternal wound infection patients was 2.51 (95% CI 1.59-3.94, P , 0:001). After adjustment for pre, intra and post-operative factors, the adjusted HR of mid-term mortality for sternal wound infection patients was 1.64 (95% CI 1.03-2.61, P ¼ 0:037). The adjusted freedom from death for sternal wound infections at 30 days, and 1, 2 and 4 years was 96.8, 93.7, 91.4 and 86.7%, respectively, compared with 98.1, 96.1, 94.7 and 91.7% for patients without sternal wound infections. Conclusions: In conclusion, we have identified risk factors for sternal wound infection, many of which are modifiable. We have also shown that there is a significant increase in mortality in patients with sternal wound infection during a 4-year follow-up period after CABG.

The Annals of thoracic surgery, 2016

Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and meta-analysis was conducted to identify risk factors associated with sternal complications. The review included 17 full-text studies, of which 10 were entered into meta-analyses. Female gender, diabetes mellitus, obesity, bilateral internal mammary artery grafts, reoperation for postoperative complications, and blood product requirement were reported as significant predictors of sternal infection. The compilation of these risk factors may help to screen and stratify patients at risk of impaired sternal healing and warrants further investigation.

Journal of Clinical Medicine

Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of 11.7 mm (sensitivi...

European Journal of Cardio-Thoracic Surgery, 2001

Select pre-, peri-, and post-operative variables, predictive for sternal wound complications (SWC), in a clinical setting. Methods: We analyzed pre-, per-, and post-operative data of 3815 patients who underwent a primary isolated bypass grafting. 100 patients (2.6%) had post-operative SWC. Unifactor and multifactor risk analysis, were used for statistical analysis.

The Annals of Thoracic Surgery, 2005

Background: Deep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality. Methods: We reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as inhospital or 30-day mortality. Risk factors for DSWI were also examined. Results: The overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups.

Advances in Clinical and Experimental Medicine, 2019

Background. Sternal dehiscence is a serious postoperative complication of cardiac surgery observed in 0.2-5% of procedures performed by median sternotomy. Objectives. Assessment of factors, including the method of sternum closure, which may affect the incidence of this complication. Material and methods. A total of 5,152 consecutive patients undergoing surgery with median sternotomy access in the Cardiac Surgery Department of the Pomeranian Medical University between 2010 and 2014 were included in the study. The analysis centered on cases of sternal dehiscence, which occurred in 45 patients (0.9%). Results. Factors such as age (p < 0.05), body mass (p < 0.005) and coronary artery bypass surgery (CABG) (p < 0.005) were found to be significant risk factors. Diabetes and chronic obstructive pulmonary disease (COPD) also had an impact on an increased risk of sternal dehiscence (p < 0.006 and p < 0.015). However, the differences were only significant in the whole study group. Apart from CABG, the type of operation did not affect the incidence of dehiscence. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass index (BMI) (odds ratio (OR): 2. 1; p < 0.019), diabetes (OR: 2.4; p < 0.004), COPD (OR: 2.7; p < 0.016), and redo procedure (OR: 3.0; p < 0.014). There were no significant differences in postoperative mortality between these groups-6.7% in the group with sternal dehiscence and 3.9% in the group without dehiscence. Conclusions. Introducing a more durable sternum stabilization method with 8+ loops helped to improve conditions for bone union and reduced the risk of dehiscence. Therefore, we suggest that centers which still use 6-loop sternal closure should consider shifting to a stronger technique.

Medical Science Monitor, 2013

This study aimed to investigate the influence of deep sternal wound infection on long-term survival following cardiac surgery.

Recent clinical techniques, results, and research in wounds, 2018

Background: Deep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality. Methods: We reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as inhospital or 30-day mortality. Risk factors for DSWI were also examined. Results: The overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups. Conclusions: The incidence of DSWI after cardiac surgery according to the data entered in the JACVSD registry during the period from 2004 to 2009 was 1.8%, and more complicated procedures were followed by higher incidence and mortality. When re-exploration for bleeding was performed, mortality was significantly higher than when it was not performed. Prevention of DSWI and establishment of an effective appropriate treatment for DSWI may improve the outcome of cardiac surgery.

Journal of Cardiothoracic and Vascular Anesthesia, 2009

The aim of this study was to investigate the incidence and predictors of deep sternal wound infection (DSWI) in a contemporary cohort of patients undergoing cardiac surgery. The early and late outcomes of patients with this complication also were analyzed. Design: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). Participants: Five thousand seven hundred ninety-eight patients who underwent cardiac surgery between January 1998 and December 2005 including isolated coronary artery bypass graft (CABG) (n ‫؍‬ 2,749, 47%), single-or multiplevalve surgery (n ‫؍‬ 1,280, 22%), combined valve and CABG procedures (n ‫؍‬ 934, 16%), and surgery involving the ascending aorta or the aortic arch (n ‫؍‬ 835, 15%). Interventions: None. Measurements and Main Results: The overall incidence of DSWI was 1.8% (n ‫؍‬ 106). The highest rate of DSWI occurred after combined valve/CABG surgery (2.4%, n ‫؍‬ 22) and aortic procedures (2.4%, n ‫؍‬ 19). Multivariate analysis revealed 11 predictors of DSWI: obesity (odds ratio [OR] ‫؍‬ 2.2), previous myocardial infarction (OR ‫؍‬ 2.1), diabetes (OR ‫؍‬ 1.7), chronic obstructive pulmonary disease (OR ‫؍‬ 2.3), preoperative length of stay >3 days (OR ‫؍‬ 1.9), aortic calcification (OR ‫؍‬ 2.7), aortic surgery (OR ‫؍‬ 2.4), combined valve/CABG procedures (OR ‫؍‬ 1.9), cardiopulmonary bypass time (OR ‫؍‬ 1.8), re-exploration for bleeding (OR ‫؍‬ 6.3), and respiratory failure (OR ‫؍‬ 3.2). The mortality rate was 14.2% (n ‫؍‬ 15) versus 3.6% (n ‫؍‬ 205) in the control group (p < 0.001). One-and 5-year survival after DSWI were significantly decreased (72.4% ؎ 4.4% and 55.8% ؎ 5.6% v 93.8% ؎ 0.3% and 82.0% ؎ 0.6%, p < 0.001). Conclusion: DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival.