[Effectiveness of Prophylactic Negative Pressure Wound Therapy after Cardiovascular Surgery through Median Sternotomy].

Negative pressure wound therapy( NPWT) is used primarily for tissue defects. In recent years, cardiovascular surgery via full sternotomy is increasingly performed through small incisions, but the rate of cardiovascular surgery through median sternotomy remains high in elderly patients, who frequently have complicated cardiovascular diseases. Mediastinitis, among other surgical site infections( SSIs), is a serious complication after cardiovascular surgery that must be resolved. Mediastinitis has a high mortality rate once it occurs, and cost of treatment and a negative impact on a patient are substantial. In some countries, NPWT is for the prophylaxis of mediastinitis, but only for cases with a significant risk of SSI. To avoid SSI, prophylactic NPWT is administered in all cardiovascular surgeries through median sternotomy at our hospital. Of 641 consecutive median sternotomy patients from March 2011 to March 2021, 601 cases were able to observe the wound for at least 30 days following the surgery. In the 601 cases, we found a statistically significant difference in the incidence of SSI. The results suggest that prophylactic NPWT significantly reduces SSI after cardiovascular surgery through median sternotomy.

Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective.

OBJECTIVES: To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). METHODS: A literature search was done over the last four decades for studies that addressed this comparison. RESULTS: Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. CONCLUSIONS: There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.

[Treatment of recurrent traumatic sternomediastinitis after cardiac surgery]. / Lechenie retsidivnogo travmaticheskogo sternomediastenita posle kardiokhirurgicheskikh operatsii.

OBJECTIVE: To assess the possibilities of omentoplasty for prevention of complications after redo sternum osteosynthesis for traumatic rupture. MATERIAL AND METHODS: The study included 53 patients with recurrent sternal diastasis. Greater omentum was additionally implanted in 19 (35.8%) cases to improve healing and reduce the risk of infectious complications. In 34 patients, redo osteosynthesis was carried out using a metal wire and deployment of irrigation-aspiration system. In 19 patients, omentoplasty was additionally used to close the wound. RESULTS: Omentoplasty was characterized by less duration of lavage (7.4±1.5 vs. 4.2±3.3 days, p<0.0001) and no cases of arrosive bleeding (p=0.04). CONCLUSION: Omentoplasty reduces duration of treatment and risk of arrosive bleeding.

Eradication of Staphylococcus aureus Post-Sternotomy Mediastinitis Following the Implementation of Universal Preoperative Nasal Decontamination With Mupirocin: An Interrupted Time-Series Analysis.

BACKGROUND: Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. METHODS: An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990-2003) and postintervention (2005-2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. RESULTS: 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P < .0001). Interrupted time-series analysis demonstrated a statistically significant annual reduction in S. aureus PSM of -9.85 cases per 1000 sternotomies (-13.17 to -6.5; P < .0001) in 2005, with a decreasing trend maintained over the following 5 years and an estimated relative reduction of 84.8% (95% confidence interval [CI], 89.25-74.09%). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio, 3.7; 95% CI, 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre- or postintervention periods. CONCLUSIONS: Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

PURPOSE: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients. METHODS: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks. RESULTS: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006). CONCLUSION: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Recent developments in controlling sternal wound infection after cardiac surgery and measures to enhance sternal healing.

One of the major risks of cardiac surgery is the occurrence of infection at the sternal wound site. Sternal wound infections are primarily classified into superficial infection and deep sternal wound infection or mediastinitis. A patient is diagnosed with mediastinitis if microorganisms are present in their mediastinal tissue/fluid or with the observation of sternal wound infection during operation and with characteristic symptoms including chest pain, fever, and purulent drainage from the mediastinum. It is usually caused by Staphylococcal organisms in 75.8% of cases and the rest is caused by gram-negative bacteria. Currently, in cardiac surgery, hemostasis is achieved using electrocautery and bone wax, and the sternum is closed using wire cerclage. Several studies show that bone wax can act as a nidus for initiation of infection and the oozing blood and hematoma at the site can promote the growth of infectious organisms. Many research groups have developed different types of biomaterials and reported on the prevention of infection and healing of the sternum. These materials are reported to have both positive and negative effects. In this review, we highlight the current clinical practices undertaken to prevent infection and bleeding as well as research progress in this field and their outcomes in controlling bleeding, infection, and enhancing sternal healing.

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis.

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra- and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.

A Technique for 360-Degree Rigid Sternal Fixation with Sternal Plates and Wire Cerclage.

Sternal instability after cardiac surgery can lead to poor bony healing, as well as deep sternal wound infections and mediastinitis. Rigid plate fixation is associated with greater stability and fewer complications compared with wire cerclage, however, rigid plate fixation alone lacks posterior stability of the sternum and may be less effective in morbidly obese or osteoporotic patients. This article describes a surgical technique of combined rigid plate fixation and wire cerclage that provides 360-degree stabilization for sternotomies in high-risk patients. We employed this technique in 40 patients with no incidence of deep sternal wound infection.

Minimization of Surgical Site Infections in Patients With Delayed Sternal Closure After Pediatric Cardiac Surgery.

BACKGROUND: Delayed sternal closure (DSC) following pediatric cardiac surgery is commonly implemented at many centers. Infectious complications occur in 18.7% of these patients based on recent multicenter data. We aimed to describe our experience with DSC, hypothesizing that our practices surrounding the implementation and maintenance of the open sternum during DSC minimize the risk of infectious complications. METHODS: We reviewed patients less than 365 days who underwent DSC between 2012 and 2016 at our institution. Infectious complications as defined by the Society of Thoracic Surgeons Congenital Heart Surgery Database were recorded. Patients with and without infectious complications were compared using Wilcoxon rank sum tests or Fisher exact tests as appropriate. RESULTS: We identified 165 patients less than 365 days old who underwent DSC, 135 (82%) of whom had their skin closed over their open sternum. Median duration of open sternum was 3 days (range: 1-32 days). Infectious complications occurred in 15 (9.1%) patients-13 developed clinical sepsis with positive blood cultures, one patient developed ventilator-associated pneumonia, and one patient developed wound infection (0.6%). No cases of mediastinitis occurred. No statistical differences in characteristics between patients with and without infectious complications could be identified. CONCLUSION: Infectious complications after DSC at our institution were notably less than reported in recent literature, primarily due to minimization of surgical site infections. Practices described in the article, including closing skin over the open sternum whenever possible, could potentially aid other institutions aiming to reduce infectious complications associated with DSC.

Clinical-care protocol for preventing mediastinitis after coronary artery bypass graft surgery: A quality improvement initiative from a private hospital.

BACKGROUND: Surgical site infections after cardiac surgery are associated with severe outcomes, including reoperation and death. We aimed to describe the effect of a standardized clinical-care protocol for preventing mediastinitis in patients who underwent coronary artery bypass graft surgery (CABG). METHODS: In a hospital certified by Joint Commission International, all patients who underwent CABG from January 2011 to December 2016 were compared in two periods according to the moment of implementation of a standardized clinical-care protocol for prevention of mediastinitis (CCPPM): pre-protocol (January 2011-December 2012) and post-protocol (January 2013-December 2016). The CCPPM consisted of the patient using a kit containing chlorhexidine 2% for bathing, mupirocin 20 mg/g for nasal topical use and chlorhexidine 0.12% for oral hygiene for 5 days before surgery, in addition to prophylaxis with a glycopeptide antimicrobial and strict glucose control (110-140 mg/dL) during surgery and immediate postoperative. RESULTS: We evaluated 1760 patients who underwent CABG in both periods. The occurrence of mediastinitis before protocol implementation was 1.44% (10 of 692 CABG). After the implementation of the protocol, there was an important reduction in the incidence of mediastinitis to 0.09% (1 of 1068 CABG) (P = 0.002). Although we did not observe a significant difference in mortality between the groups (2.3% vs 1%, P = 0.77), there was fewer in-hospital mortality due to mediastinitis after the CCPPM (0.2% vs 0%, P < 0.001). CONCLUSION: Implementation of a standardized CCPPM was associated with a significant reduction in the incidence of mediastinitis after CABG and reduction of mortality in the group of patients with mediastinitis.

Feasibility of primary sternal plating for morbidly obese patients after cardiac surgery.

BACKGROUND: Morbidly obese patients (body mass index [BMI] ≥ 35 kg/m2) who undergo cardiac surgery involving median sternotomy have a higher-than-normal risk of sternal dehiscence. To explore a potential solution to this problem, we examined the utility of transverse sternal plating for primary sternal closure in morbidly obese cardiac surgical patients. METHODS: We retrospectively reviewed data from cardiac surgical patients who underwent single primary xiphoid transverse titanium plate reinforcement for primary sternal closure from August 2009 to July 2010 (n = 8), and we compared their outcomes with those of patients with BMI ≥35 kg/m2 who underwent cardiac surgery without sternal plate reinforcement from April 2008 to July 2009 (n = 14). All cases were performed by the same surgeon. RESULTS: The 2 groups of patients had similar demographics and comorbidities (P > 0.05 for all). All patients with sternal plate reinforcement reported sternal stability at last follow-up (at a median of 27 months postoperatively; range, 8.4-49.3 months), whereas 1 patient (7.1%) who underwent standard closure developed sterile sternal dehiscence (P = 0.4). Postoperative patient-controlled analgesia (PCA) morphine usage was significantly higher for patients without sternal plate reinforcement than for patients who had sternal plate reinforcement (3.6 mg/h vs 1.3 mg/h, P = 0.008). No patient in the sternal plate group had wound seroma or perioperative complications attributable to sternal closure technique. CONCLUSION: Single xiphoid transverse plate reinforcement for primary sternal closure is a feasible option for morbidly obese patients, who are otherwise at high risk of developing sternal dehiscence. Using this technique may decrease postoperative narcotics usage. Morbidly obese patients (body mass index ≥35 kg/m2) have a higher-than-normal risk of sternal dehiscence after cardiac surgery. In a pilot study, we found that those who underwent transverse sternal plating (n = 8) had no sternal dehiscence and required less postoperative analgesia than patients who underwent standard wire closure (n = 14).

Effect of chlorhexidine skin disinfection and retrosternal gentamicin sponge on post-sternotomy mediastinitis: results from a prospective controlled registry of 2340 patients.

BACKGROUND: Reducing post-sternotomy mediastinitis (PSM) requires incorporating multiple methods. However, the independent effects of these measures are not well studied. AIM: To evaluate the independent effect of preoperative disinfection using isopropyl alcohol (IPA)-chlorhexidine gluconate (CHG) and the topical application of a retrosternal gentamicin collagen sponge at wound closure on reducing PSM. METHODS: From October 2012 to August 2014, 2340 patients were included in this prospective, controlled registry. Patients were divided into four groups. In groups 1 and 2, the skin was disinfected with IPA, and in groups 3 and 4, the skin was disinfected with IPA-CHG. A retrosternal gentamicin collagen sponge was used in groups 2 and 4. Freedom from PSM up to the 30th postoperative day was the primary endpoint. The secondary endpoint was freedom from any surgical site dehiscence. A stepwise regression model was made to reveal the independent factors associated with lower incidence of PSM. FINDINGS: There were significant differences in outcome among the groups (P < 0.0001). Primary healing was highest in group 4 (91.4%), which showed the lowest rate for mediastinitis (0.9%). Multivariate analysis showed that the use of CHG and a gentamicin sponge was statistically significant (P = 0.026 and 0.013, respectively). The other significant independent factors were valve operation (P = 0.001), body mass index >30 kg/m2 (P = 0.001), preoperative stroke (P = 0.005), and blood transfusion (P = 0.022). CONCLUSION: Preoperative skin disinfection with IPA-CHG is superior to only IPA, and it should be recommended. The addition of a retrosternal gentamicin-releasing sponge further reduces the rate of mediastinitis.

Mediastinite após cirurgias valvares cardíacas: revisão integrativa / Mediastinitis after heart valve surgeries: integrative review

A mediastinite é uma infecção do tecido conjuntivo do mediastino, pouco estudada em pacientes submetidos às cirurgias de correção de valvopatias cardíacas. O objetivo deste estudo foiidentificar na literatura as evidências relacionadas à mediastinite em pacientes submetidos às cirurgias para correção de valvopatias cardíacas. Foi realizado uma revisão integrativa com buscas, em cinco bases de dados eletrônicas: LILACS, PubMed, Scopus, EBSCOhoste Web of Science. De acordo com os critérios estabelecidos, quatro artigos foram incluídos para a análise e mostraram aspectos sobre a mediastinite, como: preditores de mortalidade no pré-operatório, contaminação de materiais no intraoperatório etécnica de abordagem cirúrgica. Estudos com enfoque específico à ocorrência de mediastinite nestes pacientes, podem instrumentalizar a equipe de saúde e melhorar a implementação das ações na prática clínica, prevenindo complicações

Mediastinitis is an infection of the connective tissue of the mediastinum that is poorly studied in patients undergoing heart valve repair surgeries. The objective of this study was to identify in the literature the evidence related to mediastinitis in patients undergoing heart valve repair surgeries. An integrative review was performed with searches in five electronic databases, namely: LILACS, PubMed, Scopus, EBSCOhost and Web of Science. According to the established criteria, were included four articles for analysis. They all had aspects about mediastinitis, such as: preoperative mortality predictors, intraoperative material contamination, and surgical approach technique. Studies focused specifically on the occurrence of mediastinitis in these patients can instrumentalize the health team andimprove the implementation of clinical practice actions by preventing complications.

[Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

[Prevention and Treatment of Mediastinitis Following Cardiac Surgery].

Mediastinitis after cardiac surgery occurs about 1% of the time and is associated with adverse effects on both short- and long-term outcomes. Therefore, prevention of mediastinitis is very important. However, when this complication occurs, a radical cure should be performed using a safe and reliable method. Many pre-, intra-, and post-operative risk factors have been reported. Perioperative management based on an understanding of the pathological condition that causes this complication is an effective prevention strategy. Early detection and treatment are most important, and there should be close coordination with plastic surgeons. Recently, negative pressure wound therapy has been used widely and appears to be effective for this complication.

Post-sternotomy mediastinitis in the modern era.

BACKGROUND: Post-sternotomy mediastinitis is associated with significant mortality and morbidity. Despite surgical advances in cardiac surgery and improvements in perioperative care, mediastinitis remains a devastating post-operative complication. This study provides a comprehension review of post-sternotomy mediastinitis in the modern era, and discusses the incidence, risk factors, microbiology, prevention, and management of this complication. METHODS: This review was based on a PubMed/MEDLINE literature search up until 9th March 2017 for publications relevant to mediastinitis post-cardiac surgery. RESULTS: The incidence of mediastinitis post-cardiac surgery varies between 0.3 and 3.4%, and is associated with an in-hospital mortality ranging from from 1.1 to 19%. The risk of developing post-operative mediastinitis is dependent on the patients' co-morbidities (diabetes, obesity, smoking, renal failure) and surgical techniques (bilateral pedicled internal mammary harvest, excessive cautery, long duration of surgery). Preventative measures including skin and nasal decontamination, antibiotic prophylaxis, strict glycemic control, and meticulous surgical techniques are crucial in reducing the risk. Treatment of post-operative mediastinitis include culture-directed antibiotic therapy, early wound exploration, and debridement followed by sternal reconstruction/closure. Vacuum-assisted therapy can be used as a single line therapy or as a bridge to eventual sternal reconstruction/closure. CONCLUSION: Post-sternotomy mediastinitis remains a potentially fatal complication of cardiac surgery despite the advancements in the perioperative care in the modern era. Management on preventative measures, prompt diagnosis, and managements are crucial in reducing associated mortality and morbidity.

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.

Total arch replacement in a patient with a tracheostoma through a reverse L-shaped partial sternotomy.

A conventional median sternotomy in a patient with a tracheostoma is susceptible to postoperative mediastinitis or graft infection after total arch replacement (TAR). An optimal surgical procedure has still not been established to circumvent these complications in such patients. We report a successful case of a 74-year-old man with a tracheostoma who received TAR through a reverse L-shaped partial sternotomy. This incision was simple and enabled us to secure an adequate operative field similar to that of a conventional median sternotomy. The patient was discharged without any evidence of infection or any other complications.

Delayed Sternal Closure in Infant Heart Surgery-The Importance of Where and When: An Analysis of the STS Congenital Heart Surgery Database.

BACKGROUND: Delayed sternal closure (DSC) is commonly used to optimize hemodynamic stability after neonatal and infant heart surgery. We hypothesized that duration of sternum left open (SLO) was associated with rate of infection complications, and that location of sternal closure may mitigate infection risk. METHODS: Infants (age ≤365 days) undergoing index operations with cardiopulmonary bypass and DSC at STS Congenital Heart Surgery Database centers (from 2007 to 2013) with adequate data quality were included. Primary outcome was occurrence of infection complication, defined as one or more of the following: endocarditis, pneumonia, wound infection, wound dehiscence, sepsis, or mediastinitis. Multivariable regression models were fit to assess association of infection complication with: duration of SLO (days), location of DSC procedure (operating room versus elsewhere), and patient and procedural factors. RESULTS: Of 6,127 index operations with SLO at 100 centers, median age and weight were 8 days (IQR, 5-24) and 3.3 kg (IQR, 2.9-3.8); 66% of operations were STAT morbidity category 4 or 5. At least one infection complication occurred in 18.7%, compared with 6.6% among potentially eligible neonates and infants without SLO. Duration of SLO (median, 3 days; IQR, 2-5) was associated with an increased rate of infection complications (p < 0.001). Location of DSC procedure was operating room (16%), intensive care unit (67%), or other (17%). Location of DSC was not associated with rate of infection complications (p = 0.45). CONCLUSIONS: Rate of occurrence of infectious complications is high among infants with sternum left open following cardiac surgery. Longer duration of SLO is associated with increased infection complications.