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Ann Thorac Surg 1998;66:92-94
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Serious wound infections after minimally invasive coronary bypass procedures

^a Division of Plastic Surgery, Jewish Hospital, University of Louisville, Louisville, Kentucky, USA

Accepted for publication February 14, 1998.

Address reprint requests to Dr Spence, Division of Thoracic and Cardiovascular Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY 40202

	Abstract

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Background. Minimally invasive coronary artery bypass grafting has become an increasingly accepted therapy for selected patients with single-vessel coronary artery disease. Reported morbidity has focused on anastomotic problems, but the occurrence of serious wound complications after these procedures has not been well documented.

Methods. We reviewed our institutional experience with 35 patients to look for the incidence of serious wound complications.

Results. Three patients had serious wound problems after minithoracotomy for coronary artery bypass graft procedures. This represents an overall 9% wound morbidity rate and a 100% rate in the obese women.

Conclusions. Wound complications at the incision site after minithoracotomy coronary artery bypass graft procedures seem to occur distinctly in obese women with redundant breasts.

	Introduction

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Minimally invasive coronary artery bypass grafting performed through a small anterior thoracotomy has become increasingly accepted as an alternative surgical treatment for patients with coronary artery disease confined to the left anterior descending coronary artery (LAD). Several groups have recently reported on the low perioperative morbidity and the more acceptable cosmetic result [1, 2]. However, wound problems after submammary incisions have not been well documented. Following up our institutional experience with 35 patients, we report 3 cases of serious postoperative wound complications isolated to female patients undergoing minithoracotomy for coronary artery bypass graft procedures. We discuss some of the possible promoting factors, and suggest an alternative surgical approach to this specific patient population.

	Case reports

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Patient 1
A 39-year-old woman presented with recurrent unstable angina caused by restenosis of a previously stented proximal lesion of the LAD. Premorbid factors included obesity, diabetes mellitus, and coronary artery disease leading to two previous anterior myocardial infarctions. A thoracoscopic dissection of the left internal thoracic artery (ITA) was performed followed by grafting to the distal LAD without cardiopulmonary bypass. Under general anesthesia, the patient was positioned in a semidecubitus position with the left shoulder elevated 30 degrees, to expose the rib cage laterally. The thoracoscope was then inserted through a separate site from the inframammary incision, and two additional stab wounds were made for insertion of the dissection instruments. Endoscopic dissection of the entire ITA was carried out using the Harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH). Next, a 7- to 8-cm incision was made in the submammary crease and the breast was dissected away from the pectoralis major muscle fascia. The chest was entered transpectorally through the fourth intercostal space without resecting the rib, and the breast was retracted upwards with the malleable metallic fingers of the CardioThoracic System retractor (Irvine, CA). A stabilized left ITA to LAD anastomosis was then performed at the selected site. After completed hemostasis, the chest was closed with pericostal absorbable sutures. The skin and subcutaneous tissue were closed using absorbable sutures to obliterate the space and no drains were left in place. The postoperative period was uneventful and she was discharged home 2 days later.

At her 14-day follow-up visit, she presented with an indurated, erythematous inferior left breast and purulent incisional drainage, with cultures positive for Staphylococcus aureus and Escherichia coli. She required hospital readmission for intravenous antibiotics, staged wound debridement, and a pectoralis major flap for closure of the defect. The wound healed well, and the patient was discharged home 1 month after the initial surgical procedure.

Patient 2
A 37-year-old obese woman with pendulous breasts and a history of recurrent unstable angina pectoris caused by subtotal occlusion of her proximal LAD was referred for surgical revascularization. Her relevant medical history included two previous anterior myocardial infarctions and hypertension. She underwent a thoracoscopic left ITA dissection and distal LAD grafting. She tolerated the procedure well and was discharged after 4 days.

Within 1 week the patient had fever and chills in association with minimal drainage from her incision. The incision, however, had begun to break down in several areas. She was hospitalized for intravenous antibiotics and local wound care. With daily dressing changes, her incision healed well by secondary intention. She did not require operative reintervention.

Patient 3
A 72-year-old obese woman with redundant breast tissue, as well as hypertension, coronary artery disease, peptic ulcer disease, and diabetes mellitus, presented with unstable angina caused by high-grade proximal LAD lesion. She underwent the minimally invasive coronary artery bypass graft procedure as previously described. The operative procedure was uneventful, as was her postoperative course.

At her 14-day follow-up, she reported a 1-day history of incisional drainage, fever, and chills. On examination, the incision was erythematous with purulent drainage and a significant subcutaneous cavity. She was admitted and treated with intravenous antibiotics after the wound was opened.

Culture results returned with an S aureus species. She required serial wound debridement followed later by wound closure with a pectoralis major muscle flap. She recovered well and was discharged at 1 month after the original coronary artery bypass graft procedure.

	Comment

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Coronary revascularization of the LAD through an anterior thoracotomy has been demonstrated to be a safe and effective alternative method for the management of myocardial ischemia in selected patients. Recent reports have commented on a low rate of complications associated with anterior thoracotomies for less invasive single-vessel coronary artery revascularization [1, 3]. Previously, concern has been focused on anastomotic problems; however, other complications, such as wound morbidity, may also be relevant. Our experience has raised the question of whether submammary incisions in obese female patients may carry an excessively high risk for postoperative morbidity, specifically wound infection. Included in this subgroup of patients were 2 women with diabetes mellitus and 3 with body mass indices exceeding 25 kg/m² (mean, 26.7 kg/m²), calculated as body weight divided by the square of the height.

The incidence of wound healing problems after intramammary incisions is reported to be between 3% and 23%. The cause of these observed cases of wound infections after anterior minithoracotomy for coronary artery bypass graft procedures is likely multifactorial [4]. One important factor may be a predisposition of the thoracic interspaces to local ischemia [4]. DeJesus and Acland [5] described in cadavers the extensive collateral blood supply to the sternum. The concept of tissue ischemia caused solely by interruption of ITA branch collaterals during harvesting lacks support, because such an abundant vascular network exists. However, they also reported a high incidence of interspaces lacking these collaterals, citing extreme variation between hemisternums and between cadavers. Thus, the subcutaneous tissue and skin of the submammary crease may overlie a relatively hypovascular interspace predisposed to ischemia. Furthermore, they noted a progressive decline in the vertical distribution of these collaterals. This finding may support the possibility of interspace ischemia as a factor in submammary wound complications, as we routinely dissect the entire ITA from the diaphragm to its proximal origin.

Other factors may promote localized ischemia at the incision site and contribute to skin breakdown. Incisions in the intertriginous areas of the body are notorious for their propensity to become infected owing to the warm, moist environment created in these regions. Contamination of the operative field caused by a break in sterile techniques is a potential problem. Breast contusion from prolonged stretching or direct pressure while accessing the submammary crease or positioning the retractor may occur. Seromas or hematomas may collect in the potential cavity created by elevating the breast tissue from the pectoralis fascia. The incidence of postoperative hematomas after anterior thoracotomy incisions is 3% to 11% [6, 7]. Finally, diabetes mellitus, well documented as a factor associated with poor wound healing [4], was a risk factor for 2 of these patients.

Concerns of pressure-induced flap necrosis and hematomas that are due to coagulation defects caused by lengthy pump runs expressed by Laks and Hammond [6] are less likely to occur with this technique of coronary artery bypass grafts. Contrary to Bedard and associates [8], who advocated the use of subpectoral drains, we have not routinely used drains except a single-tube thoracostomy.

At present, it remains unclear why this subgroup of patients might be at greater risk for wound morbidity. The many potentially complicating factors listed above have led to a reappraisal of our choice of incision for obese female patients with pendulous breasts. Despite its cosmetic disadvantages, the median sternotomy provides excellent exposure to the anterior mediastinum and carries a low incidence of wound complications. Additionally, ITA harvesting with more careful branch control can best be carried out under direct vision through a median sternotomy. Based on our observations, we now perform standard median sternotomy for off-pump internal mammary artery to LAD grafting in this particular subgroup of patients.

	Acknowledgments

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We thank Robert D. Acland, MD, for his assistance. This report was supported in part by the Jewish Hospital Heart Lung Center, Louisville, KY.

	References

Top Abstract Introduction Case reports Comment Acknowledgments References

 

1. Calafiore A.M., Teodori G., Di Giammarco G., et al. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:S72-S75.
2. Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648-1655.[Abstract/Free Full Text]
3. Shennib H., Lee A.G., Akin J. Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1997;63:988-992.[Abstract/Free Full Text]
4. Tobin G.R. Closure of contaminated wounds: biologic and technical considerations. Surg Clin North Am 1984;64:639-652.[Medline]
5. DeJesus R.A., Acland R.D. Anatomic study of the collateral blood supply of the sternum. Ann Thorac Surg 1995;59:163-168.[Abstract/Free Full Text]
6. Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
7. Brutel de la Riviere A., Brom G.H.M., Brom A.G. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101-104.[Abstract]
8. Bedard P., Keon W.J., Brais M.P., Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg 1986;41:339-341.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sebastian Pagni Ellis J. Salloum Paul A. Spence Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pagni, S. Articles by Spence, P. A. Search for Related Content PubMed PubMed Citation Articles by Pagni, S. Articles by Spence, P. A.