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Sternal wound complications--incidence, microbiology and risk factors
E Ståhle1, A Tammelin, R Bergström
1Department of Thoracic and Cardiovascular Surgery, University Hospital, Uppsala, Sweden.
Objective:
Sternal wound complications, i.e. instability and/or infection (mediastinitis), are important causes of morbidity in patients undergoing cardiac surgery via median sternotomy. Coagulase negative staphylococci, a normal inhabitant of the skin, have evolved as a cause of sternal wound infections. Since these opportunistic pathogens often are multiresistant, they can cause therapeutic problems.
Methods:
From 1980 through 1995 open heart surgery, was performed on 13,285 adult patients. Reoperation necessitated by sternal wound complications occurerd in 203 patients (1.5%). The incidence was 1.7% (168/9987) after coronary artery bypass grafting (CABG group) and 0.7% (35/3413) after heart valve surgery with or without concomitant CABG (HVR group).
Results:
Factors independently related to sternal complications in the CABG group (variable odds ratio [95% C.I.]): year of surgery, 1.9 [1.3-2.8] in 1990-1992, 2.0 [1.4-2.9] in 1993-1995; female sex, 0.4 [0.2-0.6]; diabetic disease, 1.8 [1.2-2.5]; bilateral ITA procedure, 3.3 [1.1-7.7]; and postoperative dialysis, 3.1 [1.4-6.9]. In the HVR group they were: use of ITA graft, 3.7 [1.7-7.7]; early re-exploration because of bleeding 3.0 [1.1-8.2]; and postoperative dialysis 3.1, [1.4-9.3]. Multivariate models were used to compute the risk for sternal complications in each patient. However, the prognostic models based on these risk scores provided low sensitivity and low predictive value. Patients with sternal wound complications showed no increased early mortality but worse long-term survival even after adjustment for other factors (relative hazard in CABG group 1.9 [1.2-2.8]; in HVR group 2.1 [1.1-4.3].
Conclusions:
The use of ITA grafts seems to be one of the most important factors related to sternal wound complications. However, patients at truly increased risk for this complication could not be identified on the basis of the risk factors considered in this study.
Insights
Sternal wound complications after cardiac surgery are linked to internal mammary artery grafts. Despite identifying risk factors, predicting individual patient risk remains challenging, impacting long-term survival.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Medical Complications
Background:
- Sternal wound complications, including instability and infection (mediastinitis), are significant causes of morbidity following cardiac surgery via median sternotomy.
- Coagulase-negative staphylococci, skin commensals, are increasingly implicated in sternal wound infections due to their frequent multi-drug resistance, posing therapeutic challenges.
Purpose of the Study:
- To identify risk factors associated with sternal wound complications after cardiac surgery.
- To evaluate the predictive value of identified risk factors for sternal complications.
- To assess the impact of sternal wound complications on patient mortality and long-term survival.
Main Methods:
- A retrospective analysis of 13,285 adult patients undergoing open heart surgery between 1980 and 1995.
- Calculation of complication incidence in coronary artery bypass grafting (CABG) and heart valve surgery (HVR) groups.
- Multivariate logistic regression models were employed to determine independent risk factors for sternal complications.
Main Results:
- The overall incidence of sternal wound complications requiring reoperation was 1.5% (203/13,285).
- Independent risk factors included year of surgery, female sex, diabetes, bilateral internal thoracic artery (ITA) procedures, and postoperative dialysis in the CABG group.
- In the HVR group, ITA graft use, early re-exploration for bleeding, and postoperative dialysis were significant risk factors.
- Prognostic models showed low sensitivity and predictive value.
- Sternal wound complications were associated with worse long-term survival, even after adjusting for other factors.
Conclusions:
- Internal thoracic artery (ITA) grafts appear to be a significant factor contributing to sternal wound complications.
- Current risk factors considered in this study are insufficient to accurately identify patients at truly increased risk for sternal complications.