Prevention and management of deep sternal wound infection
Gilbert H L Tang1, Manjula Maganti, Richard D Weisel
1Division of Cardiovascular Surgery, Toronto General Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Abstract:
Deep sternal wound infection (DSWI) is an uncommon but serious complication of median sternotomy in cardiac surgery, associated with significant mortality and morbidity. We performed a retrospective review of 30,102 consecutive cardiac surgical patients operated on at our institution from 1990 to 2003 and found an incidence of DSWI of 0.77%. The in-hospital mortality rate was 6.9% for DSWI patients versus 2.8% for patients without DSWI (P = 0.0002). Multivariable predictors for development of DSWI were old age, diabetes, previous stroke or TIA, and congestive heart failure. The use of bilateral internal thoracic artery (BITA) grafts increased the risk of DSWI in patients undergoing coronary artery bypass surgery, particularly in those with congestive heart failure alone or with diabetes. Skeletonization of BITA grafts resulted in a lower risk of DSWI, comparable to nondiabetic patients (1.3% versus 1.6%, P = 0.8). Patients with DSWI were treated with either sternal debridement and primary closure or sternectomy with myocutaneous flap reconstruction, resulting in a 6-month freedom from adverse event rate of 76% in both groups.
Insights
Deep sternal wound infection (DSWI) after cardiac surgery is rare but serious. Bilateral internal thoracic artery grafts increase DSWI risk, especially in diabetic patients, but skeletonization may mitigate this.
Area of Science:
- Cardiology
- Thoracic Surgery
- Infectious Disease
Background:
- Deep sternal wound infection (DSWI) is a severe complication following median sternotomy in cardiac surgery.
- DSWI significantly increases patient mortality and morbidity.
Purpose of the Study:
- To determine the incidence, risk factors, and outcomes of DSWI in a large cohort of cardiac surgery patients.
- To evaluate the impact of bilateral internal thoracic artery (BITA) grafting and graft skeletonization on DSWI risk.
Main Methods:
- Retrospective review of 30,102 cardiac surgical patients from 1990-2003.
- Multivariable analysis to identify predictors of DSWI.
- Comparison of DSWI incidence and outcomes between different surgical techniques and patient groups.
Main Results:
- The incidence of DSWI was 0.77%, with a significantly higher in-hospital mortality rate (6.9%) compared to non-DSWI patients (2.8%).
- Predictors for DSWI included older age, diabetes, prior stroke/TIA, and congestive heart failure.
- BITA grafts increased DSWI risk, particularly in patients with heart failure or diabetes; skeletonization of BITA grafts reduced this risk.
Conclusions:
- DSWI is associated with increased mortality, and specific patient factors predict its development.
- Surgical techniques, including the use and preparation of BITA grafts, influence DSWI risk.
- Both debridement/closure and flap reconstruction are effective in managing DSWI, achieving similar long-term outcomes.
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