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Ann Thorac Surg 1998;65:1050-1056
© 1998 The Society of Thoracic Surgeons
a Division of Cardiovascular Surgery, The Toronto Hospital, and Centre for Cardiovascular Research and the Collaborative Program in Cardiovascular Sciences, University of Toronto, Toronto, Ontario, Canada
Accepted for publication November 7, 1997.
Address reprint requests to Dr Weisel, Division of Cardiovascular Surgery, The Toronto Hospital, EN 14-215, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Methods. Retrospective review was performed using prospectively gathered data on 12,267 consecutive cardiac surgical patients from 1990 to 1995. Chart review was performed on all patients in whom DSWI developed, and follow-up was obtained on 100% of these patients.
Results. Deep sternal wound infections developed in 92 patients (incidence 0.75%). Multivariable predictors for development of DSWI in all patients were (odds ratios and 95% confidence intervals in parentheses) (1) diabetes mellitus (2.6; 1.7 to 4.0) and (2) male sex (2.2; 1.3 to 3.9). In patients receiving coronary artery bypass grafting alone, independent predictors were (1) bilateral internal thoracic artery grafts (3.2; 1.1 to 8.9), (2) diabetes (2.7; 1.6 to 4.3), and (3) male sex (1.8; 0.9 to 3.7). For all other patients, predictors were (1) age more than 74 years (3.3; 1.1 to 10.1), (2) male sex (3.0; 1.1 to 8.1), and (3) diabetes (2.3; 0.9 to 5.8). Bilateral internal thoracic artery grafts increased the risk of DSWI in all subgroups of coronary artery bypass graft patients, particularly in diabetics who had a 14.3% incidence of DSWI after bilateral internal thoracic artery grafting. Patients with DSWIs received either sternal debridement with primary closure (n = 45) or sternectomy with flap reconstruction (n = 46). The 6-month freedom from adverse event rate (ie, readmission, reoperation, or death) was 76% for both groups of patients.
Conclusions. Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral internal thoracic artery grafting may be contraindicated in diabetic patients.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Several studies have examined risk factors for development of DSWI [2–4]. Commonly quoted risk factors include obesity, chronic obstructive pulmonary disease, elderly age, peripheral vascular disease, reoperation, use of internal thoracic artery (ITA) conduits, operation time, low cardiac output, ventilation time, and reexploration for bleeding. Several studies have also examined treatment options for DSWI [1, 5–8]. Therapeutic options include debridement with early or delayed closure, closed continuous irrigation, and partial or complete sternectomy with flap reconstruction. The purpose of this study was to (1) determine the risk factors for DSWI in a cohort of cardiac surgical patients; (2) evaluate the potential for risk factor modification; and (3) analyze the outcomes of the two treatment protocols for DSWI used in this population, sternal debridement with primary closure and sternectomy with flap reconstruction.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Perioperative management
Patients were showered and shaved the day of their operation. All patients received intravenous cefazolin, or vancomycin if allergic to penicillins, preoperatively and for 48 hours postoperatively. The operative field was painted with povidone-iodine solution and the skin was covered with an iodoform-impregnated adhesive plastic sheet (Ioban; 3M, Brookings, SD). The skin was incised with a scalpel and electrocautery was used to open the presternal layers and pericardium. Bone wax was used only if sternal bleeding was profuse. Internal thoracic arteries were harvested as pedicled in situ grafts when used for coronary bypass. Sump drains were placed in the mediastinum, and chest tubes were inserted into the pleural spaces if opened. The sternum was closed with stainless steel wires. The presternal space was obliterated with two layers of absorbable suture, and the skin was closed with a subcuticular absorbable suture. Patients were extubated when they were hemodynamically stable, normothermic, and ventilating spontaneously. All drains were removed the morning after operation or when drainage was less than 25 mL/h.
Management of infection
Seventy-one of the 92 patients (77%) were diagnosed with DSWI on the same admission as their cardiac surgical procedure. All discharged patients with wound infections are readmitted to our institution under the attending cardiovascular surgeon. Patients were started on broad-spectrum antibiotics when the diagnosis of sternal wound infection was made. Ninety-one of the 92 patients with DSWI underwent surgical therapy (the remaining patient had a cardiac arrest and died on the way to the operating room). Patients underwent either sternal debridement with primary closure (n = 45) or sternectomy with muscle flap reconstruction (n = 46) at the discretion of the attending surgeon. In general, however, patients underwent prompt, simple sternal debridement, without closed irrigation, if the infection was thought to be localized to a small section of the sternum and there was little or no purulent drainage. Patients received flap reconstruction if there was evidence of mediastinitis, if a large amount of purulent drainage was present, or if the majority of the wound was thought to be involved. All flap reconstructions were performed by the Toronto Hospital plastic surgery consultants.
Study variables
Multiple variables were recorded prospectively and analyzed retrospectively as predictors of DSWI. Patients were divided into two groups: those with DSWI (n = 92) and those without DSWI (control patients, n = 12,175). Comparisons of baseline demographics and intraoperative and postoperative variables were made between the two groups of patients to identify predictors of DSWI. These variables and their definitions are listed in Appendix 1.
Follow-up
Postoperative follow-up was obtained on 100% of patients. Follow-up was performed to identify events that occurred within 6 months of the surgical treatment for the sternal wound infection. Follow-up was completed first by review of the surgeon’s office chart and then by telephone interview with the patient or his or her family physician.
Statistical methods
Univariate analysis was performed using the 
2 test (or Fisher’s exact test, where appropriate) for categorical variables and two-tailed Student’s t test for continuous variables. All variables suggested by the univariate analysis (p < 0.25) or those judged to be clinically important were entered into a stepwise multiple logistic regression analysis model. That model with the best Hosmer-Lemeshow goodness of fit statistic and receiver-operator characteristic curve were chosen, as previously described [10]. All analyses were performed using the SAS program (SAS Institute, Cary, NC).
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Patients who acquired DSWI had longer intensive care unit stays (7.7 ± 11.1 versus 2.5 ± 3.6 days, p < 0.001) and hospital stays (32 ± 21 versus 10 ± 9 days, p < 0.001) than patients who did not have DSWI. Perioperative mortality was also higher in patients with DSWI (9.8% versus 3.7%, p = 0.002).
A univariate analysis of potential risk factors for development of DSWI was performed using the variables listed in Table 1, and a definition of these variables is supplied in Appendix 1. Significant preoperative predictors of DSWI were male sex, body mass index, diabetes, smoking status, and chronic obstructive pulmonary disease. Intraoperative predictors were cardiopulmonary bypass time, operation time, use of left ITA graft, and use of bilateral ITA grafts. Postoperative predictors were low cardiac output syndrome, ventilation time, and postoperative resternotomy. (Postoperative resternotomy refers to patients returning to the operating room after their cardiac surgical procedure for bleeding, dehiscence, or delayed primary closure of the sternum. It does not refer to patients with a previous history of cardiac operation performed through a median sternotomy.)
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Of the three multivariable predictors of DSWI in CABG patients, only the use of bilateral ITA grafts is under the surgeon’s discretion. The other risk factors, male sex and diabetes, are known at the time a decision is made whether or not to perform bilateral ITA grafts. We therefore examined the risk of development of DSWI in male and diabetic CABG patients, with and without bilateral ITA grafts (see Fig 2). The incidence of DSWI was 0.7% in CABG patients not receiving bilateral ITA grafts versus 2.2% in those receiving bilateral ITA grafts (p = 0.029). In male CABG patients, bilateral ITA grafts raised the risk of DSWI from 0.8% to 2.6% (p = 0.020). Similarly, diabetic patients had an increased risk of DSWI with bilateral ITA grafts from 1.3% to 14.3% (p = 0.001). Male diabetic patients undergoing CABG went from a baseline incidence of DSWI of 1.6% to 20.0% with the addition of bilateral ITA grafts (p = 0.001).
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Patients were divided into two groups according to the operative procedure for their wound infection—sternal debridement with primary closure in 45 patients and sternectomy with muscle flap reconstruction in 46 patients—and follow-up data were collected to examine outcomes for each of these groups of patients. One patient had a cardiac arrest and died on the way to the operating room and is excluded from any of the follow-up data. Of the 46 patients who underwent sternectomy with muscle flap reconstruction, 41 received bilateral pectoralis flaps and 5 received combined pectoralis and rectus abdominis flaps. As stated previously, the decision as to which operative procedure the patients would receive was at the discretion of the attending surgeon, with patients tending to receive debridement alone if the infection was thought to be localized, and flap reconstruction if there was gross purulent drainage or evidence of mediastinitis.
The median length of time from date of initial cardiac operation to diagnosis of DSWI was 12 days in those patients receiving flap reconstruction (range, 3 to 71 days) and 11 days in those receiving debridement (range, 3 to 27 days). The median length of time from diagnosis of DSWI to date of operative therapy for DSWI was 3 days in the flap group (range, 0 to 33 days) and 1 day in the debridement group (range, 0 to 36 days).
Follow-up was obtained on 100% of patients, with the median length of time to follow-up being 11.4 months after the operative procedure for infection (range, 7.3 to 50.1 months). To capture only those events related directly to the sternal wound infection, data are displayed only for the first 6 months of follow-up. Outcome data is supplied in an intention-to-treat format for the two groups of patients (ie, if patients underwent a different operative procedure for a second operation for infection, they were still classified by the original operative procedure for infection). Figure 3 displays the 6-month event-free survival for patients undergoing sternal debridement, which was 75.6% ± 2.9%. Three of the 45 patients (6.7%) in the debridement group had persistent sepsis postoperatively leading to multisystem organ failure and death, despite repeat surgical interventions in 2 of the 3 patients. Seven patients (15.6%) required a reoperation for control of infection. These 7 patients all received a pectoralis flap for the second operative procedure, and 2 suffered ongoing sepsis and eventually died. Two debridement patients (4.4%) required readmission to the hospital as a direct result of the infection; however, both of these patients received conservative treatment with good recovery. Figure 4 displays the outcomes for patients receiving sternectomy with flap reconstruction for their DSWI. The 6-month event-free survival was 76.1% ± 2.9% for this group of patients. Five flap patients (10.9%) had persistent sepsis postoperatively with resultant multisystem organ failure and death, despite repeat surgical interventions in 3 of these patients. Any reoperation was required in 6 of the 46 patients (13.0%) undergoing flap reconstruction as the initial operative procedure. Four of the 6 patients requiring reoperation underwent repeat flap procedures (of which 2 died of ongoing sepsis), 1 underwent simple drainage of a hematoma with no adverse sequelae, and 1 underwent multiple debridements of the flap before dying of uncontrolled sepsis. Readmission for complications related to sternal infection was required in 3 patients (6.5%), with all 3 patients being treated conservatively with good recovery.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Our multiple logistic regression analysis revealed two independent predictors of DSWI in the entire cohort of patients: diabetes and male sex (Fig 1, top panel). Diabetes is known to impair wound healing and cellular and humoral immunity, which may increase the risk of infection [16]. Male sex is cited as a risk factor for DSWI in at least two other studies [2, 15], including a prospective, multicenter study performed by the Parisian Mediastinitis Study Group [2]. The reason for male sex as an independent predictor is unclear, particularly in view of the fact that female sex is traditionally associated with increased morbidity and mortality in cardiac surgical patients. It may be that males tend to have increased tension on their sternal incision, which in turn leads to increased risk of sternal instability. Sternal rewiring for dehiscence was performed in 41 patients during the time period of this study, of which a large proportion (17.1%) went on to have DSWI.
We divided patients into two groups—isolated CABG and all other patients—to assess the risk of bilateral ITA grafting on the development of DSWI. Only isolated CABG patients received bilateral ITA grafts at our institution. Bilateral ITA grafting was a strong univariate predictor of DSWI in our overall patient population. The middle and bottom panels of Figure 1 display the factor-adjusted odds ratios for the predictors of DSWI in these two patient subpopulations. The use of bilateral ITA grafts was the strongest predictor of DSWI in CABG patients, followed by diabetes and male sex. In all other cardiac surgical patients independent predictors of DSWI were age more than 74 years, male sex, and diabetes, in decreasing order. Elderly age has been associated with sternal wound infection in other studies [13, 20].
Left ITA grafting to the left anterior descending coronary artery increases bypass graft patency rates and decreases late cardiac events. Extraarterial grafts may result in further improvements in patency rates and cardiac events. The use of bilateral ITA grafts, however, may lead to increased risk of DSWI by decreasing sternal blood flow [11, 12]. The risk of DSWI in patients receiving bilateral ITA grafts is controversial, with some studies suggesting no increased risk in selected patients [1, 13] and others finding a consistent increase in risk in all patient groups [2, 14]. Figure 2 demonstrates that in patients undergoing CABG at our institution, bilateral ITA grafts significantly increased the risk of DSWI in all subgroups of patients. In particular, diabetic patients who received bilateral ITA grafts had a much higher incidence of DSWI compared with those who did not (14.3% versus 1.3%, p = 0.001). There were 14 diabetic patients who received bilateral ITA grafts in this study population, of which 3 were insulin-dependent and 11 were diet-controlled or on oral hypoglycemic agents. Two diabetic patients had DSWI: 1 insulin-dependent patient and 1 with diet-controlled diabetes. We would therefore conclude that any type of diabetes is a significant risk factor for development of DSWI for patients receiving bilateral ITA grafts.
Risk factor identification permits the assessment of factors that may be modifiable. Of the risk factors for DSWI identified in this study, only the use of bilateral ITA grafts is at the surgeon’s discretion. Bilateral ITA grafts demonstrate excellent patency rates and may decrease long-term mortality [16, 17]. However, our findings would suggest that diabetes is a contraindication to the use of bilateral ITA grafting. If extraarterial grafts are being contemplated for a diabetic patient, we would suggest the use of other arterial conduits, such as the radial, inferior epigastric, or gastroepiploic artery.
The results of wound cultures are presented in Table 2. As in several previous studies, the most common organisms were S aureus and coagulase-negative staphylococci [1, 14, 19], followed by multiple-organism infections. Patients with multiple organisms cultured from the sternal wound had a high incidence of preexisting infections at distant sites, in contrast to those with staphylococcal infections (60% versus 15%, p = 0.002). Staphylococcal infections may be caused by wound contamination from local skin flora, whereas multiple-organism infections may be caused by hematogenous spread or by contamination from distant sites.
Patients with DSWI were divided into two groups according to the operative therapy chosen for their wound infection: sternal debridement with primary closure or sternectomy with flap reconstruction. The choice of therapy depended on the clinical status of the patient, and therefore outcomes for the two groups cannot be directly compared. However, we can state that patients receiving debridement underwent operative therapy earlier than those undergoing flap reconstruction (median length of time from diagnosis of DSWI to operative therapy 1 versus 3 days, respectively.) This was probably related to the fact that flap reconstructions were performed in conjunction with plastic surgeons at our institution, and therefore required coordination of operative schedules. Follow-up was obtained on 100% of patients and results are displayed for the 6-month period after the operative intervention for DSWI for both groups of patients inFigures 3 and 4. Both treatment strategies resulted in a 6-month event-free survival of approximately 75%. Mortality was high in both groups, occurring in 6.7% of debridement patients and 10.9% of flap patients. We did not identify any complications attributable to the infection that occurred later than 6 months after operative intervention for DSWI.
In conclusion, DSWI is a devastating complication of operations performed through a median sternotomy. Although the incidence of this complication is low (0.75% in our study population), high-risk patients can be identified. Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral ITA grafting increased the risk of DSWI in all subgroups of CABG patients. Diabetic patients receiving bilateral ITA grafts have a 14% incidence of DSWI, and we therefore suggest against the use of bilateral ITA grafts in this population. Long-term follow-up reveals that a good result can be achieved in 75% of patients treated with debridement or sternectomy with flap reconstruction [18].
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Acknowledgments |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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Appendix 1 |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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References |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsAppendix 1References |
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G.G. Santos, N.A.G. Stolf, L.F.P. Moreira, V.L.S. Haddad, R.M.C. Simoes, S.R.V. Carvalho, A.A. Salgado, and S.F. Avelar Jr. Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1009 - 1014. [Abstract] [Full Text] [PDF]
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M. Ura, R. Sakata, Y. Nakayama, and Y. Arai Bilateral pedicled internal thoracic artery grafting Eur. J. Cardiothorac. Surg., June 1, 2002; 21(6): 1015 - 1019. [Abstract] [Full Text] [PDF]
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S. Dogan, T. Aybek, E. Andre{beta}en, C. Byhahn, S. Mierdl, K. Westphal, G. Matheis, A. Moritz, and G. Wimmer-Greinecker Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: Report of forty-five cases J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1125 - 1131. [Abstract] [Full Text] [PDF]
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R. Wettstein, D. Erni, P. Berdat, D. Rothenfluh, and A. Banic Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1185 - 1190. [Abstract] [Full Text] [PDF]
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N.A. Scott, J.L. Knight, B.P. Bidstrup, H. Wolfenden, R.N. Linacre, and G.J. Maddern Systematic review of beating heart surgery with the Octopus(R) Tissue Stabilizer Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 804 - 817. [Abstract] [Full Text] [PDF]
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L. Ridderstolpe, H. Gill, H. Granfeldt, H. Ahlfeldt, and H. Rutberg Superficial and deep sternal wound complications: incidence, risk factors and mortality Eur. J. Cardiothorac. Surg., December 1, 2001; 20(6): 1168 - 1175. [Abstract] [Full Text] [PDF]
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I. Risnes, M. Abdelnoor, S. Tore Baksaas, R. Lundblad, and J. L. Svennevig Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques Ann. Thorac. Surg., November 1, 2001; 72(5): 1587 - 1591. [Abstract] [Full Text] [PDF]
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A. Combes, J.-L. Trouillet, J. Baudot, M. Mokhtari, J. Chastre, and C. Gibert Is it possible to cure mediastinitis in patients with major postcardiac surgery complications? Ann. Thorac. Surg., November 1, 2001; 72(5): 1592 - 1597. [Abstract] [Full Text] [PDF]
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 A. Iwakura, Y. Tabata, N. Tamura, K. Doi, K. Nishimura, T. Nakamura, Y. Shimizu, M. Fujita, and M. Komeda Gelatin Sheet Incorporating Basic Fibroblast Growth Factor Enhances Healing of Devascularized Sternum in Diabetic Rats Circulation, September 18, 2001; 104 (2009): I-325 - I-329. [Abstract] [Full Text] [PDF]
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D. Pevni, A. Kramer, Y. Paz, O. Lev-Run, C. Locker, M. Matsa, I. Shapira, and R. Mohr Composite arterial grafting with double skeletonized internal thoracic arteries Eur. J. Cardiothorac. Surg., August 1, 2001; 20(2): 299 - 304. [Abstract] [Full Text] [PDF]
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M. De Feo, R. Gregorio, A. Della Corte, C. Marra, C. Amarelli, A. Renzulli, R. Utili, and M. Cotrufo Deep sternal wound infection: the role of early debridement surgery Eur. J. Cardiothorac. Surg., June 1, 2001; 19(6): 811 - 816. [Abstract] [Full Text] [PDF]
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S. M. Fiser, C. G. Tribble, J. A. Kern, S. M. Long, A. K. Kaza, and I. L. Kron Cardiac reoperation in the intensive care unit Ann. Thorac. Surg., June 1, 2001; 71(6): 1888 - 1893. [Abstract] [Full Text] [PDF]
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M. Lemma, G. Gelpi, A. Mangini, P. Vanelli, C. Carro, A. Condemi, and C. Antona Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery Ann. Thorac. Surg., June 1, 2001; 71(6): 1969 - 1973. [Abstract] [Full Text] [PDF]
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L. Noyez, J. A.M. van Druten, J. Mulder, A. M.A. Schroen, S. H. Skotnicki, and R. M.H.J. Brouwer Sternal wound complications after primary isolated myocardial revascularization: the importance of the post-operative variables Eur. J. Cardiothorac. Surg., April 1, 2001; 19(4): 471 - 476. [Abstract] [Full Text] [PDF]
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M. De Feo, A. Renzulli, G. Ismeno, R. Gregorio, A. Della Corte, R. Utili, and M. Cotrufo Variables predicting adverse outcome in patients with deep sternal wound infection Ann. Thorac. Surg., January 1, 2001; 71(1): 324 - 331. [Abstract] [Full Text] [PDF]
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P. C. Ng, A. N. Chua, M. S. Swanson, T. C. Koutlas, W. R. Chitwood Jr, and J. R. Elbeery Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass Ann. Thorac. Surg., May 1, 2000; 69(5): 1338 - 1340. [Abstract] [Full Text] [PDF]
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B. Korbmacher, H.H. Schmitt, G. Bauer, M. Hoffmann, H. Vosberg, O. Simic, and E. Gams Change of sternal perfusion following preparation of the internal thoracic artery - a scintigraphical study Eur. J. Cardiothorac. Surg., January 1, 2000; 17(1): 58 - 62. [Abstract] [Full Text] [PDF]
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W. E. Trick, W. E. Scheckler, J. I. Tokars, K. C. Jones, M. L. Reppen, E. M. Smith, and W. R. Jarvis MODIFIABLE RISK FACTORS ASSOCIATED WITH DEEP STERNAL SITE INFECTION AFTER CORONARY ARTERY BYPASS GRAFTING J. Thorac. Cardiovasc. Surg., January 1, 2000; 119(1): 108 - 114. [Abstract] [Full Text] [PDF]
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A. G. Royse, C. F. Royse, and J. S. Raman Exclusive Y graft operation for multivessel coronary revascularization Ann. Thorac. Surg., November 1, 1999; 68(5): 1612 - 1618. [Abstract] [Full Text] [PDF]
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A. G. Royse, C. F. Royse, P. Shah, A. Williams, S. Kaushik, and J. Tatoulis Radial artery harvest technique, use and functional outcome Eur. J. Cardiothorac. Surg., February 1, 1999; 15(2): 186 - 193. [Abstract] [Full Text] [PDF]
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J. Bellchambers, J.M. Harris, P. Cullinan, H. Gaya, and J.R. Pepper A prospective study of wound infection in coronary artery surgery Eur. J. Cardiothorac. Surg., January 1, 1999; 15(1): 45 - 50. [Abstract] [Full Text] [PDF]
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