Current Challenges in the Treatment of Deep Sternal Wound Infection Following Cardiac Surgery (original) (raw)
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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.
Epidemiology of Deep Sternal Wound Infection in 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.
Deep Sternal Wound Infection After Cardiac Surgery: Modality of Treatment and Outcome
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.
Deep Sternal Wound Infection After 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.
Heart, Lung and Circulation, 2011
Background: Deep sternal wound infection (DSWI) is a rare but severe complication following cardiac surgery. Our study investigated the risk factors and treatment options for patients who developed DSWI at our institution between May 1988 and April 2008. Method: Data was collected prospectively in a database and information on demographics reviewed retrospectively on 5649 patients who underwent cardiac surgery during this period. Results: The incidence of DSWI was 34/5649 (0.6%). These patients were older (mean age 66.1 vs. 64.5), more likely to die (in hospital mortality 11.8% vs. non DSWI group 1.8%) and had longer hospital stays (DSWI group mean stay 25 days vs. non DSWI group 9 days). Using Fisher's exact test the risk predictors for DSWI determined at our institution included diabetes managed with oral medications (p = 0.021), previous cardiac surgery (p = 0.038), BMI ≥ 30 (p = 0.041), LVEF ≤ 30 (p = 0.010), IABP usage (p = 0.028) and homologous blood usage (p < 0.001). Most commonly bilateral pectoralis major muscle flap (BPMMF) was used for treatment of DSWI (11/30, 36.7%). Conclusion: Ultimately our data was comparable to published data in the literature on known risk predictors.
Deep Sternal Wound Infection: Risk Factors and Outcomes
The Annals of Thoracic Surgery, 1998
Background. Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution.
Risk factors and treatment of deep sternal wound infection after cardiac operation
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia, 2003
Although deep sternal wound infection (DSWI) after cardiac surgery is infrequent, its consequences are serious. The purposes of this study were to define the risk factors, and to establish the best surgical treatment for DSWI. Retrospective analysis for 863 patients who underwent cardiac surgery was performed. The patients were divided into the DSWI group (n=17) and the non-infection group (n=846). Preoperative, perioperative, and postoperative variables were compared between the two groups using univariate and multivariate logistic regression analysis. The modality of treatment for DSWI was also analyzed. The incidence of DSWI was 1.97%. Independent predictors for DSWI were concomitant coronary artery bypass grafting (CABG) with valve or aortic surgery [odds ratio, 4.1; 95% confidence interval, (1.1, 15.1)] and postoperative use of intraaortic balloon pumping [4.4, (1.6, 12.3)]. An independent predictor in isolated CABG patients was emergency operation [10.9, (2.7, 44.7)]. Four of ...
Procedure- and Hospital-Level Variation of Deep Sternal Wound Infection From All-Japan Registry
The Annals of Thoracic Surgery, 2020
Background. The outcome of cardiovascular surgery has been improving over time, but the treatment of postoperative complications such as deep sternal wound infection (DSWI) still needs critical attention. A nationwide surgical registry was analyzed for procedural details and hospital factors related to DSWI. Methods. The study used the Japan Adult Cardiovascular Surgery Database, which captured data from 82% of all the hospitals performing cardiac surgery in Japan. A total of 109,717 surgical cases (34,980 coronary artery bypass grafting, 43,602 valve operations, 31,135 thoracic aortic operations) were included in the study. Results. The overall incidence of DSWI was 1738 (1.6%). The 30-day mortality and operative mortality were 3311 (3.0%) and 5155 (4.7%), respectively. Across the 3 procedures, thoracic aortic operation showed the highest odds ratio (2.61; 95% confidence interval [CI], 2.32 to 2.94) for operative mortality but the lowest (0.91; 95% CI:,0.73 to 1.13) for DSWI incidence. Conversely, coronary artery bypass grafting showed the lowest odds ratio (1.36; 95% CI, 1.24 to 1.49) for operative mortality but the highest (1.52; 95% CI, 1.32 to 1.76) for DSWI. There was also hospital-level variation: Correlation was statistically significant between the observed-to-expected ratio of DSWI incidence and the observed-to-expected mortality ratio of cardiovascular procedures across the hospitals, but the coefficient was small (r [ .24, P < .001). Conclusions. Hospitals that have a lower risk-adjusted mortality rate of cardiovascular procedures do not always have a lower risk-adjusted DSWI occurrence rate. In addition, the incidence of DSWI varies across hospitals. We need to consider DSWI independently of surgical mortality, whereas for treatment we should consider both the specific hospital environment and the multidisciplinary care.
Early and late sternal wound infections following open heart surgery
2013
Infections of the sternal wound are among the most serious complications after open heart surgery. These infections result in increased morbidity for patients, can sometimes be fatal, and are associated with increased costs. Deep sternal wound infections (DSWIs) are the most common and serious of these infections. Late infections, which can result in formation of sternocutaneous fistulas (SCFs), are encountered less often, although they often represent a complex surgical problem involving several hospital admissions, prolonged antibiotic treatment, and repeated wound debridements. For the last two decades, more efficient treatments have been developed for these infections, which has lowered mortality-especially after the introduction of negative-pressure wound therapy (NPWT). In NPWT, polyurethane foam is placed in a debrided wound covered with a sterile wound drape, and a tube for transmission of negative pressure to facilitate wound healing is attached, increasing the likelihood of successful closure. The aims of the work presented in this thesis, which consists of four peer reviewed papers (I-IV), were twofold. First, to analyze the incidence, risk factors, microbiology, and outcome of DSWI in Iceland, concentrating on the outcome of NPWT. Second, to study the same outcome parameters for SCF in two well-defined cohorts of patients, one in Sweden and the other in Iceland. Clinical information was gathered from hospital charts and was registered electronically. When possible risk factors for both DSWI and SCF were evaluated, multivariate analysis was used with a case-control design and survival was analyzed using either direct comparison or the Kaplan-Meier method. In Paper I, a population-based study of DSWI in Iceland is described, involving a total of 41 patients diagnosed between 1997 and 2004, or 2.5% of all patients who underwent open heart surgery during the period. The most common pathogens were Staphylococcus aureus and coagulase-negative staphylococci (CoNS) in 41% and 37% of cases, respectively. The strongest independent risk factors were: peripheral arterial disease (odds ratio (OR) = 6.4), re-operation due to bleeding (OR = 4.5), cerebrovascular accident (OR = 4.3), obesity (OR = 3.0), low left ventricular ejection fraction (OR = 2.9), and history of smoking (OR = 2.9). The in-hospital mortality during this study period was 10% among DSWI cases, as compared to 4% in controls (p = 0.17). The one-year mortality was significantly higher in DSWI cases: 17% vs. 6% (p = 0.02). Patients with DSWI stayed an average of 33 days longer in hospital for treatment.