Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial.

BACKGROUND: One factor for the development of sternal wound infection (SWI) is bony instability after sternotomy. This study compares two surgical techniques with respect to the occurrence of SWI in patients with an increased risk. METHODS: In this multicenter study, 815 consecutive patients with an increased risk for SWI were prospectively randomly assigned to a conventional osteosynthesis (transsternal or peristernal wiring; n = 440) or to an osteosynthesis with additional lateral reinforcement (Robicsek; n = 375). Primary endpoints were the rate of sternal dehiscence as well as the occurrence of superficial sternal wound infections and deep sternal wound infections. RESULTS: Both groups were comparable concerning preoperative and intraoperative variables. The rate of sternal dehiscence, superficial sternal wound infections, and deep sternal wound infections (conventional technique 2.5%, 3.4%, 2.5%; and Robicsek 3.7%, 5.6%, 3.7%) did not differ between the groups. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass indes greater than 30 kg/m(2) (odds ratio [OR]: 2.9; p = 0.05), New York Heart Association class more than III (OR: 2.4; p = 0.07), impaired renal function (OR: 3.9; p = 0.01), peripheral arterial disease (OR: 3.6; p = 0.001), immunosuppressant state (OR: 3.3; p = 0.001), sternal closure performed by an assistant doctor (OR: 2.5, p = 0.004), postoperative bleeding (OR: 4.2; p = 0.03), transfusion of more than 5 red blood units (OR: 3.7, p = 0.01), reexploration for bleeding (OR: 6.9, p = 0.001), and postoperative delirium (OR: 3.5, p = 0.01). There was an inverse relation between the numbers of wires and DSWI in patients with conventional sternal closure (p = 0.008). CONCLUSIONS: In patients with an increased risk for sternal instability and wound infection after cardiac surgery, sternal reinforcement according to the technique described by Robicsek did not reduce this complication.

Pulmonary valve replacement for pulmonary thrombus formation after previous aortic valve replacement, Guillain-Barré syndrome and enterococcal sepsis.

Acquired disease of the pulmonary valve requiring surgery is rare. We report the case of a 70-year-old male presenting with pulmonary valve insufficiency and pulmonary emboli originating from a thrombus formation adhering to the pulmonary valve occurring despite dicoumarol anticoagulation for previous aortic valve surgery. Two years ago he experienced Guillain-Barré syndrome and one year ago enterococcal sepsis which were treated medically. Apart from a previous prolonged ICU stay no predisposing factors for right sided endocarditis could be found. The pulmonary lesion was surgically corrected with removal of the thrombus and excision of the pulmonary valve. Reconstruction of the valve and pulmonary artery was performed with a semistentless xenograft valved conduit.