Risk factors for sternal wound infection after median sternotomy: A nested case-control study and time-to-event analysis.

Although potential risk factors for sternal wound infection (SWI) have been extensively studied, the onset time of SWI and different risk factors for superficial and deep SWI were rarely reported. This nested case-control study aims to compare the onset time and contributors between superficial and deep SWI. Consecutive adult patients who underwent cardiac surgery through median sternotomy in a single center from January 2011 to January 2021 constituted the cohort. The case group was those who developed SWI as defined by CDC and controls were matched 6:1 per case. Kaplan-Meier analysis, LASSO and univariate and multivariate Cox regressions were performed. A simple nomogram was established for clinical prediction of the risk of SWI. The incidence of SWI was 1.1% (61 out of 5471) in our cohort. Totally 366 controls were matched to 61 cases. 26.2% (16 of 61) SWI cases were deep SWI. The median onset time of SWI was 35 days. DSWI had a longer latency than SSWI (median time 46 days vs. 32 days, p = 0.032). Kaplan-Meier analyses showed different time-to-SWI between patients with and without DM (p = 0.0011) or MI (p = 0.0019). Multivariate Cox regression showed that BMI (HR = 1.083, 95% CI: 1.012-1.116, p = 0.022), DM (HR = 2.041, 95% CI: 1.094-3.805, p = 0.025) and MI (HR = 2.332, 95% CI: 1.193-4.557, p = 0.013) were independent risk factors for SWI. Superficial SWI was only associated with BMI (HR = 1.089, 95% CI: 1.01-1.175, p = 0.027), while deep SWI was associated with DM (HR = 3.271, 95% CI: 1.036-10.325, p = 0.043) and surgery time (HR = 1.004, 95% CI: 1.001-1.008, p = 0.027). The nomogram for SWI prediction had an AUC of 0.67, good fitness and clinical effectiveness as shown by the calibration curve and decision curve analyses. BMI, DM and MI were independent risk factors for SWI. DSWI had a longer latency and different risk factors compared to SSWI. The nomogram showed a fair performance and good effectiveness for the clinical prediction of SWI.

[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. / Posleoperatsionnyi sternomediastinit: morfologiya porazheniya, taktika lecheniya.

OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.

Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery.

OBJECTIVES: Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy. DESIGN: A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored. RESULTS: The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04). CONCLUSIONS: Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.

Bleeding in minimally invasive versus conventional aortic valve replacement.

BACKGROUND: Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. METHODS: This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. RESULTS: Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. CONCLUSIONS: Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. CLINICAL TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov . Unique identifier: NCT02272621.

Outcomes and Risk Factors Associated with Pericardiectomy in Patients with Constrictive Pericarditis: A Retrospective Study from China.

PURPOSE: Pericardiectomy is the definitive treatment option for constrictive pericarditis and is associated with a high prevalence of morbidity and mortality. However, information on the associated outcomes and risk factors is limited. We aimed to report the mid-term outcomes of pericardiectomy from a single center in China. METHODS: We retrospectively reviewed data collected from patients who underwent pericardiectomy at our institute from April 2018 to January 2023. RESULTS: Eighty-six consecutive patients (average age, 46.1 ± 14.7 years; 68.6 men) underwent pericardiectomy through midline sternotomy. The most common etiology was idiopathic (n = 60, 69.8%), and 82 patients (95.3%) were in the New York Heart Association function class III/IV. In all, 32 (37.2%) patients underwent redo sternotomies, 36 (41.9%) underwent a concomitant procedure, and 39 (45.3%) required cardiopulmonary bypass. The 30-day mortality rate was 5.8%, and the 1-year and 5-year survival rates were 88.3% and 83.5%, respectively. Multivariable analysis revealed that preoperative mitral insufficiency (MI) ≥moderate (hazard ratio [HR], 6.435; 95% confidence interval [CI] [1.655-25.009]; p = 0.007) and partial pericardiectomy (HR, 11.410; 95% CI [3.052-42.663]; p = 0.000) were associated with increased 5-year mortality. CONCLUSION: Pericardiectomy remains a safe operation for constrictive pericarditis with optimal mid-term outcomes.

Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac Surgery: A Meta-Analysis.

INTRODUCTION: It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic. METHODS: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05). RESULTS: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95). CONCLUSION: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy.

INTRODUCTION: Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI. METHODS: We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed. RESULTS: All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps. CONCLUSIONS: We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

The prophylactic use of negative-pressure wound therapy after cardiac surgery: a meta-analysis.

Surgical site infections (SSIs) pose a frequent complication in cardiac surgery patients and lead to increased patient discomfort and extended hospitalization. This meta-analysis aimed to evaluate the protective role of single-use negative-pressure wound therapy (sNPWT) devices on closed surgical wounds after cardiac surgery, and explored their potential preventive application across all cardiac surgery patients. A comprehensive literature search was conducted on ScienceDirect, focusing on studies related to "negative pressure wound therapy" or "PICO negative pressure wound therapy" combined with "cardiac surgery" or "sternotomy," published between 2000 and 2022. Inclusion criteria encompassed case-control studies comparing sNPWT with traditional dressings on closed cardiac surgical incisions in adult patients undergoing median sternotomy without immediate postoperative infective complications, with available details on SSIs. A retrospective analysis of cases treated with sNPWT in our centre was also performed. The meta-analysis revealed a protective role of sNPWT, indicating a 44% risk reduction in overall SSIs (odds ratio 0.56) and a 40% risk reduction in deep wound infections (odds ratio 0.60). Superficial wound infections, however, showed non-significant protective effects. A single-centre study aligned with the meta-analysis findings, confirming the efficacy of sNPWT and was included in the meta-analysis. In conclusion, the meta-analysis and the single-centre study collectively support the protective role of negative pressure wound therapy against overall and deep SSIs, suggesting its potential prophylactic use on all cardiac surgery populations.

Engineering Wet-Resistant and Osteogenic Nanocomposite Adhesive to Control Bleeding and Infection after Median Sternotomy.

Median sternotomy surgery stands as one of the prevailing strategies in cardiac surgery. In this study, the cutting-edge bone adhesive is designed, inspired by the impressive adhesive properties found in mussels and sandcastle worms. This work has created an osteogenic nanocomposite coacervate adhesive by integrating a cellulose-polyphosphodopamide interpenetrating network, quaternized chitosan, and zinc, gallium-doped hydroxyapatite nanoparticles. This adhesive is characterized by robust catechol-metal coordination which effectively adheres to both hard and soft tissues with a maximum adhesive strength of 900 ± 38 kPa on the sheep sternum bone, surpassing that of commercial bone adhesives. The release of zinc and gallium cations from nanocomposite adhesives and quaternized chitosan matrix imparts remarkable antibacterial properties and promotes rapid blood coagulation, in vitro and ex vivo. It is also proved that this nanocomposite adhesive exhibits significant in vitro bioactivity, stable degradability, biocompatibility, and osteogenic ability. Furthermore, the capacity of nanocomposite coacervate to adhere to bone tissue and support osteogenesis contributes to the successful healing of a sternum bone defect in a rabbit model in vivo. In summary, these nanocomposite coacervate adhesives with promising characteristics are expected to provide solutions to clinical issues faced during median sternotomy surgery.

Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis.

PURPOSE: Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified. RESULTS: We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI, -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks. CONCLUSION: The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required. STUDY REGISTRATION: PROSPERO (CRD42022306914); first submitted 22 March 2022.

RéSUMé: OBJECTIF: Il existe plusieurs contre-indications aux stratégies analgésiques multimodales traditionnelles chez la patientèle de chirurgie cardiaque, ce qui oblige les clinicien·nes à se tourner vers d'autres options. Les blocs des plans intercostaux parasternaux superficiels, anesthésiant les branches cutanées antérieures des nerfs intercostaux thoraciques, sont l'une des méthodes simples actuellement explorées pour traiter la douleur après une sternotomie. Nous avons cherché à évaluer la littérature sur les effets des blocs parasternaux superficiels sur le contrôle de la douleur après une chirurgie cardiaque. MéTHODE: Nous avons réalisé une revue systématique et une méta-analyse des études randomisées contrôlées (ERC). Nous avons fait des recherches dans les bases de données MEDLINE, Embase, CENTRAL et Web of Science pour en tirer les ERC évaluant les blocs des plans intercostaux parasternaux superficiels chez les patient·es adultes bénéficiant d'une chirurgie cardiaque par sternotomie médiane publiées depuis leur création jusqu'au 11 mars 2022. Le critère d'évaluation principal préspécifié était la consommation d'opioïdes à 12 heures. Le risque de biais a été évalué à l'aide de l'outil Cochrane Collaboration Risk of Bias, et la qualité des données probantes à l'aide de l'outil GRADE. Les résultats ont été analysés à l'aide d'un modèle à effets aléatoires. Tous les sous-groupes étaient préspécifiés. RéSULTATS: Nous avons examiné 1275 citations. Onze ERC, comprenant 756 patient·es, remplissaient les critères d'inclusion. Une seule étude a rapporté le critère d'évaluation principal préspécifié, ce qui a exclu la possibilité d'une méta-analyse. Cette étude a rapporté une réduction de la consommation d'opioïdes (−11,2 mg équivalents de morphine iv; intervalle de confiance [IC] à 95 %, −8,2 à −14,1). Il y a eu une réduction de la consommation d'opioïdes à 24 heures (−7,2 mg équivalents de morphine iv; IC 95 %, −5,6 à −8,7; cinq études; 436 participant·es; données probantes de certitude modérée). Les cinq études mesurant les complications ont rapporté qu'aucune complication n'avait été détectée, en incluant un échantillon de 196 blocs. CONCLUSION: La littérature suggère un avantage potentiel de l'utilisation de blocs parasternaux superficiels pour améliorer le contrôle de la douleur postopératoire aiguë après une chirurgie cardiaque par sternotomie médiane. Des études futures précisant les schémas posologiques et les adjuvants sont nécessaires. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022306914); soumis pour la première fois le 22 mars 2022.

Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial.

STUDY OBJECTIVE: This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy. DESIGN: A double-blind, prospective, randomized, placebo-controlled trial. SETTING: University-affiliated tertiary care hospital. PATIENTS: 60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy. INTERVENTIONS: The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone. MEASUREMENTS: The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented. MAIN RESULTS: Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016). CONCLUSIONS: Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.

A novel manual therapy approach for managing acute interscapular pain following median sternotomy for open cardiac surgery: A clinical comparative analysis.

INTRODUCTION: Acute interscapular pain is a frequent postoperative complication observed in patients who have undergone median sternotomy. This study aimed to assess a novel approach to manual therapy utilizing the Regional Interdependence (RI) concept for managing interscapular pain in post-sternotomy patients. MATERIALS AND METHODS: In an observational study, a cohort of 60 consecutively admitted patients undergoing median sternotomy was enrolled. Data collection involved standardized clinical evaluations conducted at specific time points: prior to manual treatment (T0), following five manual treatments (T5), and at post-treatment days 10 (T10) and 30 (T30). The Experimental Group (EG) received manual treatment based on the RI concept, performed in a seated position to accommodate individual clinical conditions and surgical wound considerations. The Control Group (CG) received simulated treatment involving identical exercises to the EG but lacking the physiological or biomechanical stimulation. RESULTS: Among the initial 60 patients, 36 met the inclusion criteria, while 24 were excluded due to one or more exclusion criteria. Treatment outcomes revealed a statistically significant improvement in the EG compared to the CG, not only in terms of pain reduction but also in functional recovery and consequent disability reduction. DISCUSSION: The RI concept emerges as a potentially valuable therapeutic approach for addressing interscapular dysfunction, particularly in highly complex post-sternotomy patients. This study highlights the clinical relevance of the RI concept in the management of interscapular pain and highlights its potential utility in improving patient outcomes in the challenging context of sternotomy surgery.

Reducing Sternal Wound Infection Rates in Patients Undergoing Cardiothoracic Surgery with Sternotomy.

LOCAL PROBLEM: Sternal wound infections (SWIs), whether superficial or deep, are associated with increased morbidity, mortality, and costs. From 2016 to 2017, our facility saw a 50% decrease in SWIs among patients undergoing cardiothoracic surgery with sternotomy. From 2017 to 2018, however, we identified a 33% increase in SWIs, prompting us to address our cardiac nurses' sternal wound care education and practice. PURPOSE: The purpose of our quality improvement (QI) project was to identify opportunities for improvement in postoperative sternal incision care and to implement evidence-based processes to reduce the incidence of SWIs among cardiothoracic surgery patients. METHODS: A literature review was performed to identify interventions focused on evidence-based SWI reduction. During the first quarter of 2019, our postoperative incision care guidelines were revised and released to staff, a new surgical wound cleansing product was supplied, and RN education was provided. Cardiac nurses were surveyed in April 2019 to identify any remaining knowledge and practice deficits and to assess their adherence to the new guidelines. The survey responses helped us to further improve our nurse education. We also provided periodic nurse reeducation and enhanced patient and family education. All such interventions were implemented by the end of June 2019. RESULTS: Between January and June 2019, we had one SWI. From July 2019 through December 2020, an 18-month period, we experienced zero SWIs. Although beginning in 2021, we saw an increase in SWIs-four in 2021 and five in 2022-our incidence rates remain below 0.5% and we continue to work toward an SWI goal of zero. CONCLUSION: This QI project identified opportunities for improvement, implemented evidence-based strategies for wound care and education, and successfully achieved a zero SWI rate for a period of 18 months.

Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study.

INTRODUCTION: Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. METHODS: We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. RESULTS: The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). CONCLUSION: MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

Flap management following orthotopic heart transplantation: A single institution's review of 66 sternal wound complications.

BACKGROUND: Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population. METHODS: A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure. RESULTS: The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes. CONCLUSIONS: Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results.

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients. DESIGN: A prospective, randomized, double-blind, comparative study. SETTING: At a single institution tertiary referral cardiac center. PARTICIPANTS: A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups. CONCLUSION: Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients.

[Pay attention to the prevention and treatment of deep sternal wound infection after sternotomy].

Deep sternal wound infection (DSWI) is one of the potential and catastrophic complications after cardiac surgery. Despite the use of smaller incisions, routine application of prophylactic antibiotic and optimized blood glucose management, the incidence rate of DSWI still fluctuates between 1% and 5%. The early symptoms and signs of DSWI are not often obvious, making it too late for the clinicians to intervene in the process. Once left untreated, DSWI carries a very high mortality rate. Therefore, early prevention, diagnosis, and appropriate management of DSWI are crucial in preventing its progression to life-threatening outcomes. Considering the clinical severity and treatment complexity of DSWI, this article focuses on preventive experiences in each stage of DSWI, and reconstructive strategies after DSWI happens, raising attention among the medical community regarding DSWI.

[Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects].

Objective: To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy, and to evaluate its clinical effects. Methods: This study was a retrospective observational study. From January 2017 to December 2022, 36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University, including 23 males and 13 females, aged 25 to 81 years. Preparation for surgery was made. For patients with suspected retrosternal mediastinal abscess cavity, all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum, remove the source of infection and granulation tissue, and to fill the sternum defect with flipped unilateral pectoralis major muscle. For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, the necrotic tissue and a small amount of necrotic sternum were palliatively removed, and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect. After the skin in the donor area was closed by tension-relieving suture, continuous vacuum sealing drainage was performed, and continuous even infusion and lavage were added 24 hours later. The thorax was fixed with an armor-like chest strap, the patients were guided to breathe abdominally, with both upper limbs fixed to the lateral chest wall using a surgical restraint strap. The bacterial culture results of wound exudation specimens on admission were recorded. The wound condition observed during operation, debridement method, muscle flap covering method, intraoperative bleeding volume, days of postoperative infusion and lavage, lavage solution volume and changes on each day, and postoperative complications and wound healing time were recorded. After discharge, the wound healing quality, thorax shape, and mobility functions of thorax and both upper limbs were evaluated during follow-up. The stability and closure of sternum were observed by computed tomography (CT) reexamination. Results: On admission, among 36 patients, 33 cases were positive and 3 cases were negative in bacterial culture results of wound exudation specimens. Intraoperative observation showed that 26 patients had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, palliative debridement was performed and bilateral pectoralis major muscles were advanced and abutted to cover the defect. In 10 patients with suspected retrosternal mediastinal abscess cavity, the local sternum was completely removed by bite and the defect was covered using flipped unilateral pectoralis major muscle. During the operation, one patient experienced an innominate vein rupture and bleeding of approximately 3 000 mL during mediastinal exploration, and the remaining patients experienced bleeding of 100-1 000 mL. Postoperative infusion and lavage were performed for 4-7 days, with a lavage solution volume of 3 500-4 500 mL/d. The lavage solution gradually changed from dark red to light red and finally clear. Except for 1 patient who had suture rupture caused by lifting the patient under the armpit during nursing on the 3rd day after surgery, the wounds of the other patients healed smoothly after surgery, and the wound healing time of all patients was 7-21 days. Follow-up for 3 to 9 months after discharge showed that the patient who had suture rupture caused by armpit lifting died due to multiple organ failure. In 1 patient, the armor-like chest strap was removed 2 weeks after surgery, and the shoulder joint movement was not restricted, resulting in local rupture of the suture, which healed after dressing change. The wounds of the remaining patients healed well, and they resumed their daily life. The local skin of patient's pectoralis major muscle defect was slightly sunken and lower than that of the contralateral thorax in the patients undergoing treatment of pectoralis major muscle inversion, while no obvious thoracic deformity was observed in patients undergoing treatment with pectoralis major muscle propulsion and abutment. The chest and upper limb movement in all patients were slightly limited or normal. CT reexamination results of 10 patients showed that the sternum was stable, the local sternum was closed or covered completely with no lacuna or defects. Conclusions: Once the wound associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy is formed, individualized and precise debridement should be performed as soon as possible, different transfer ways of pectoralis major muscle flap should be chosen to cover the defect, and postoperative continuous infusion and lavage together with strict thorax and shoulder joint restraint and immobilization should be performed. This treatment strategy can ensure good wound healing without affecting the shape and function of the donor area.

Computed Tomography Scanning for Sternal Wound Infections: A Systematic Review.

Background: Sternal wound infection (SWI) has always been a significant risk in patients who undergo sternotomies as part of their cardiac surgical procedures. Computed tomography (CT) imaging is often used to diagnose and assess sternal wound infections. Its purpose includes identifying and locating infection and any sternal dehiscence. Methods: A systematic literature review across PubMed, Embase, and Ovid was performed according to PRISMA guidelines to identify relevant articles that discussed the utility of CT scanning for SWI, common features identified, patient outcomes and sensitivity/specificity (Figure 1). Results: 25 papers were included. 100% (n=25) of the papers were published in peer-reviewed journals. CT scans in SWIs can be seen as a beneficial aid in diagnosing as well as determining the components of infection. Commonalities were identified such as fluid collection in the mediastinum, free gas, pleural effusions, and sternal dehiscence which point towards the presence of sternal wound infection. Conclusion: CT scanning is a novel and emerging methodology for imaging in SWI and post-sternotomy complications, hence increased research is required to expand the literature on this area as well as the creation of guidelines and cut-offs or signs for radiology professionals to identify and determine the extent of infection.