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Major bleeding complicating deep sternal infection after cardiac surgery
Alon Yellin1, Yael Refaely, Michael Paley
1Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Israel. ayellin@sheba.health.gov.il
Insights
Major bleeding after deep sternal infection is a serious complication following cardiac surgery. Meticulous wire removal techniques may reduce the risk of this bleeding event.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Surgical Complications
Background:
- Deep sternal infection (DSI) is a rare but severe complication after cardiac surgery.
- Major bleeding can occur during the management of DSI, significantly impacting patient outcomes.
Purpose of the Study:
- To determine the incidence and outcomes of major bleeding in patients with DSI post-cardiac surgery.
- To identify predisposing factors, preventive measures, and management strategies for major bleeding in DSI.
Main Methods:
- A retrospective study of 10,863 cardiac surgery patients was conducted.
- 280 patients with deep sternal infection were analyzed, including 15 who experienced major bleeding.
Main Results:
- Major bleeding occurred in 5.36% of patients with DSI.
- Bleeding was most common after coronary artery bypass grafting and often originated from the right ventricle.
- The overall mortality rate for patients with major bleeding was high (53.3%).
Conclusions:
- Major bleeding in DSI is not linked to the initial cardiac surgery but carries a high mortality risk.
- Careful technique during wire removal may lower the incidence of major bleeding.
- The roles of cardiopulmonary bypass and sternal reconstruction techniques in bleeding remain unclear.
Objectives:
This study was undertaken to determine the incidence and outcome of major bleeding complicating deep sternal infection after cardiac surgery, to identify predisposing factors and means of prevention, and to clarify management options.
Methods:
This was a retrospective study of 10,863 consecutive patients, of whom 213 (2.18%) acquired deep sternal infection. With 43 additional referrals, the total number of patients with deep sternal infection was 280. Deep sternal infection was managed by a two-stage scheme. Major bleeding was considered to be bleeding that occurred during or after operation for deep sternal infection from the heart, great vessels, or grafts, or bleeding requiring urgent exploration.
Results:
Fifteen patients (5.36%) had major bleeding. The incidences of deep sternal infection and bleeding were highest among patients undergoing coronary artery bypass grafting. Thirteen patients had underlying diseases (type 2 diabetes in 9 cases). Deep sternal infection was diagnosed a median of 15 days after reoperation. Bleeding originated from the right ventricle in 9 patients. In 4 patients bleeding was iatrogenic during surgery for wire removal (n = 2) or reconstruction (n = 2). In 11 it occurred 15 minutes to 15 days (median 2 days) after wire removal, as a result of shearing forces in 7 cases and of infection only in 4 cases. Three patients died immediately. The other 12 were operated on, 6 with complete cardiopulmonary bypass, 2 with femoral cannulation, and 4 without cardiopulmonary bypass. The immediate mortality was 26.7%; the overall mortality was 53.3%. The median length of hospitalization of surviving patients was 38 days.
Conclusions:
The probability of development of major bleeding in patients with deep sternal infection was unrelated to the primary operation. The mortality associated with this complication was high. Meticulous technique during wire removal may decrease the risk of major bleeding. The impacts of cardiopulmonary bypass and of the technique and timing of sternal reconstruction remain undetermined.
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