Sternal instability following coronary artery bypass grafting

Several cases of sternal instability have been noted in patients following coronary artery bypass graft surgery attending our cardiac rehabilitation programme. The purpose of this prospective study was to identify factors associated with sternal instability following sternotomy involving saphenous vein grafts (SVG) and unilateral or bilateral internal mammary artery (IMA) grafts. A rating scale for quantifying sternal instability was developed and used by the physiotherapists to assess all patients. Inter-therapist and intra-therapist reliabilities for the scale were calculated and these were 0.97 and 0.98 (ICC) respectively. Twenty-four patients who underwent coronary artery bypass grafting with a sternotomy incision presented with the complication of sternal instability 6-8 weeks following surgery. They represented 16.3% of the 147 patients presenting for cardiac rehabilitation who had undergone surgery interstate over an 18-month period. Sternal symptoms reported were pain, crepitus, and/or clicking at rest or on trunk and upper limb motion. Risk factors to wound healing such as obesity, diabetes, bilateral IMA grafting, osteoporosis, repeat operations, and prolonged post-operative mechanical ventilation were noted. A significantly higher proportion of patients with bilateral IMA grafting (31.5%) as opposed to unilateral IMA grafting (14.3%) had sternal instability (P <. 05). Quantifying the degree of sternal instability may play a role in identifying management options, patient progression and the point of intervention.     

Mycobacterium tuberculosis sternal wound infection after open heart surgery: a case report and review of the literature

Tuberculous osteomyelitis of sternum after open heart surgery is a rare disease entity. We report a case of wound infection with osteomyelitis caused by Mycobacterium tuberculosis in a patient with diabetic nephropathy, requiring peritoneal dialysis after coronary artery bypass grafting, who was successfully treated with antituberculous agents and surgical debridement. In addition, we provide a literature review on reported cases of tuberculous sternal osteomyelitis and mediastinitis after open heart surgery, and discuss about the risk factors, clinical features, and treatment of this infection.     

Correlation of preoperative factors, severity of disease, type of oxygenator and perfusion times with mortality and morbidity of coronary bypass

Previous studies have related preoperative status and severity of disease to the outcome of coronary artery bypass surgery. Although increased perfusion and clamp times increase the risk of cardiac surgical procedures, the importance of these factors in relation to the patient's preoperative condition and the severity of disease has not previously been determined. In this study of 1078 patients, we examined the correlation between the patient's preoperative condition, the severity of coronary disease, and duration of perfusion and clamp time, and the type of oxygenator used with the mortality and morbidity associated with coronary artery bypass grafting. One-way analysis of variance and multiple correlation analysis showed that perfusion time, clamp time and nonclamp perfusion time correlated with mortality, perioperative infarction, the use of intra-aortic balloon pump, stroke, renal failure, pulmonary failure, infection, and leg wound complications (p less than 0.05). Perfusion time, clamp time and nonclamp perfusion time did not correlate with postoperative bleeding or sternal wound complications. Nonclamp perfusion time correlated more strongly than any other factor with mortality, perioperative infarction, the use of intra-aortic balloon pump, renal failure, pulmonary failure and infection (p less than 0.05). Clamp time correlated more than any other factor with the development of leg-wound complications (p less than 0.05). The use of a bubble rather than a membrane oxygenator was significantly related to mortality, stroke, infection and leg wound complications by one-way analysis of variance (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review

BackgroundDeep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI.MethodsA literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded.ResultsThe review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05).ConclusionIn this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.     

双侧乳内动脉搭桥术的疗效及影像学随访:基于64例60~75岁糖尿病患者

目的 探讨老年（60~75岁）糖尿病患者接受双侧乳内动脉（BIMA）搭桥手术的早期（3月）疗效及影像学随访结果,总结针对该类患者的诊疗经验。 方法 回顾性分析2015年12月~2017年8月于我科接受BIMA搭桥术的64例老年患者,将其按是否患有糖尿病分为糖尿病组和非糖尿病组。糖尿病组36例,男性25例,女性11例,年龄62.83±2.60岁;非糖尿病组28例,男性23例,女性5例,年龄62.29±1.76岁。分析两组患者术前一般情况、术中资料（主动脉阻断时间、体外循环时间、手术时间等）、术后常见并发症的发生率、影像学随访结果等资料,探讨该类患者的早期手术疗效,总结诊疗经验。 结果 糖尿病组“左主干+三只血管病变”的患病率及术前糖化血红蛋白水平均高于非糖尿病组（P=0.025、0.001）。两组患者在骨骼化获取乳内动脉例数、手术时间、体外循环时间、主动脉阻断时间、乳内动脉桥的即刻血流量及搏动指数（PI值）等方面差异无统计学意义（P > 0.05）。两组患者胸部切口愈合不良、乳糜胸等常见并发症的发生率差异无统计学意义（P > 0.05）;4例患者合并术后胸部切口并发症,其术前的糖化血红蛋白水平高于其他患者（P < 0.001）。冠脉CT血管造影结果显示,两组患者术后早期桥血管的闭塞率差异无统计学意义（P > 0.05）。 结论 相较于非糖尿病的老年患者而言,老年糖尿病患者的冠脉病变较重,但BIMA搭桥术的手术难度无增加,在适当治疗的基础上可获得满意的早期疗效,冠脉CTA作为该类患者早期的随访方法结果较满意。      

Women and cardiac rehabilitation: referral and compliance patterns

Heart disease is the primary killer among American women. Differences in referral for cardiac rehabilitation, as well as compliance rates, have been reported between male and female cardiac patients. This study explored the use of Phase I and Phase II cardiac rehabilitation programs by male and female patients. In particular, the study aimed to investigate the relationship between eligibility and subsequent referral to Phase II cardiac rehabilitation in both men and women, as well as their compliance rates in completing Phase II. In addition, for those patients who never started a Phase II program, their reasons for nonparticipation were explored. Structured patient interviews and chart audits were used to explore cardiac rehabilitation eligibility criteria, referral and completion rates. The sample consisted of 87 patients (46 women and 41 men) who were admitted with a medical diagnosis of angina, myocardial infarction, coronary artery bypass grafting, or valve replacement surgery. Men had higher eligibility rates for Phase I, whereas women had higher eligibility rates for Phase II; more men received a referral for Phase II from their physician than women did. Men had a higher completion rate with Phase II compared with women. For those patients who chose not to start a Phase II program, the most common reasons cited included transportation problems, insurance issues, and having exercise equipment at home. Although women are being referred for cardiac rehabilitation, fewer complete the programs. Continued education is essential to teach women the importance of cardiac rehabilitation to overall recovery and adaptation to an acute cardiac event. In addition, cardiac rehabilitation programs must be structured to meet the unique needs of women and thereby remove obstacles that have prevented higher participation rates by women in the past.     

Prevalence of leg wound complications after coronary artery bypass grafting: determination of risk factors.

BACKGROUND: The reported prevalence of leg wound complications after coronary artery bypass grafting is 2% to 24%. Decreased length of hospital stay for patients who have this surgical procedure poses new care requirements in both acute care and community settings. OBJECTIVE: To determine the prevalence of postoperative leg wound complications in patients undergoing coronary artery bypass grafting and the risk factors associated with these complications. METHOD: In this prospective, observational study, 547 consecutive patients who had coronary artery bypass grafting alone or in combination with other cardiac surgical procedures were examined for evidence of leg wound complications each day after surgery during hospitalization. After discharge, problems were detected by home care nurses. RESULTS: The prevalence of leg wound complications was 6.8%. Factors significant by multiple logistic regression included preoperative hospitalization, use of an Ace elastic bandage in the operating room, the length of time the leg incision remained open in the operating room, and administration of nicardipine intravenously in the intensive care unit. Odds ratios were calculated for each variable. Premorbid factors such as diabetes or peripheral vascular disease were not predictive of complications. On average, most problems occurred on postoperative day 10, when many patients were at home. CONCLUSIONS: The results highlight the need to detect complications early, in both the hospital and the community settings. The determination of factors related to poor outcomes may assist clinicians in improving healthcare delivery.     

先天性心脏病术后延迟关胸的护理

目的探讨先天性心脏病术后延迟关胸术患儿的护理方法。方法对28例行延迟关胸术的患儿进行伤口、体温、心功能等方面的监测,总结护理经验。结果28例延迟关胸中4例因手术后低心排死亡,其余24例在全身水肿减轻,循环稳定情况下行二期关胸术,延迟关胸时间2~5 d,本组除1例有伤口渗血,3例肺部感染(2例为革兰氏阴性菌)外,其余均无感染发生。结论延迟关胸术可提高复杂先心病的早期生存率。术后良好的监护能及时发现问题,预防和减少并发症的发生。     

Introducing the Cardibra: a randomised pilot study of a purpose designed support bra for women having cardiac surgery.

BACKGROUND: Cardiac nurses instruct women to wear a brassiere (bra) after a sternotomy for cardiac surgery to reduce lateral tension on the wound. However this practice is rarely implemented because regular bras impede nursing care in the immediate postoperative period. The Cardibra was developed to address the inadequacies of the regular bra and provide an alternate method of breast support. AIM: To develop a purpose designed support bra (the Cardibra) and evaluate its effectiveness on sternal wound healing and the reduction of pain for women who had a sternotomy for cardiac surgery. METHODS: The study consisted of two stages. Stage 1 described the development of the Cardibra. Stage 2 was a pilot study of a clinical trial, prospective, randomised two-group design. The treatment group consisted of 10 women using the Cardibra immediately following surgery and the control group of 10 who wore a regular bra 3 days post surgery. Repeated measures at six time points assessed pain levels and wound healing. RESULTS: This study indicated that the Cardibra might have beneficial therapeutic effects on pain levels and wound healing up to day 14 after cardiac surgery. CONCLUSION: This innovative device may offer therapeutic benefits to women following cardiac surgery.     

Management and outcomes of delayed sternal closure after cardiac surgery in neonates and infants

OBJECTIVES: To investigate the efficacy, safety, and patterns of management of open sternotomy and delayed sternal closure in infants who were left with an open sternum after cardiac surgery and to assess these patterns for possible correlation with outcome. DESIGN: Retrospective chart review with statistical analysis. SETTING: Pediatric cardiac surgery service at a regional referral center based in an urban university teaching hospital. PATIENTS: All 128 patients <1 yr of age who were left with an open sternum after cardiac surgery with cardiopulmonary bypass during the 4-yr period from July, 1992 to June, 1996. INTERVENTIONS: Procedures for managing open sternotomy and delayed sternal closure were analyzed retrospectively. No interventions were undertaken for the study. MEASUREMENTS AND RESULTS: Of the 128 patients, 14 (11%) died before sternal closure; delayed sternal closure was performed in the remaining 114. Of these 114, 13 died in the early postoperative period. During sternal closure, significant increases were noted in pulmonary arterial (from 21.1+/-7.6 mm Hg to 26.1+/-6.5 mm Hg; p = .006), left atrial (from 8.4+/-3.4 mm Hg to 11.5+/-3.7 mm Hg; p < .001), and right atrial pressures (from 7.3+/-2.5 mm Hg to 9.8+/-2.5 mm Hg; p < .001). In addition, mean airway pressure (from 7.4+/-2.0 mm Hg to 8.6+/-2.4 mm Hg; p < .001) and peak inspiratory pressure (from 29.3+/-5.4 mm Hg to 31.3+/-5.6 mm Hg; p = .004) increased. Sternal wound infection occurred in one patient. CONCLUSIONS: Delayed sternal closure is an effective approach to the management of neonates and infants at risk for hemodynamic, respiratory, or hemostatic instability early after cardiac surgery. Significant changes in hemodynamics and respiratory variables occur during sternal closure, often requiring adjustment of inotropic and ventilatory management. (Crit Care Med 2000; 28: 1180-1184) KEY WORDS: cardiopulmonary bypass; mechanical ventilation; postoperative complications; sternal wound infection; cardiopulmonary interaction     

Cardiac surgery in kidney and liver transplant recipients

OBJECTIVE: To evaluate operative management, outcome, and long-term survival in patients with functioning renal and hepatic allografts who underwent cardiac surgery. PATIENTS AND METHODS: We studied all patients who had previously undergone either renal or hepatic transplantation and who subsequently (1986-2001) underwent cardiac surgery at our institution. Data were obtained by retrospective medical record analysis. RESULTS: The study comprised 47 patients with renal (n=34) and hepatic (n=13) functioning allografts. Median time to cardiac surgery from transplantation was 79 months. The most common procedures were as follows: coronary artery bypass grafting, 22 (47%); aortic valve procedures, 11 (23%); and mitral valve procedures, 5 (11%). One patient (2%) died within 30 days of surgery. Renal allograft dysfunction was noted in 5 renal patients (15%) immediately after surgery. Two patients required dialysis postoperatively, 1 of whom required continued dialysis on dismissal. Transient allograft dysfunction, as determined by elevated liver enzyme levels, occurred in 6 hepatic patients (46%). However, all hepatic patients had functional allografts on dismissal. Two patients (4%) developed leg wound infections, and 9 (19%) had respiratory complications. No sternal or mediastinal infection occurred. One- and 5-year survival rates (mean +/- SEM) for all patients were 93%+/-4% and 76%+/-8%, respectively. Of the renal patients, 1- and 5-year survival rates (mean +/- SEM) were 97%+/-3% and 82%+/-8%, respectively. One- and 5-year survival rates (mean +/- SEM) for hepatic patients were 77%+/-12% and 69%+/-13%, respectively. CONCLUSION: Cardiac surgery can be performed safely in kidney and liver transplant recipients, with low early mortality and excellent medium-term survival. In almost all instances, allograft function is well preserved.     

Sternal wound infections: improvements made to reduce rates

Wound infections from surgical sites account for 15% of all healthcare-associated infections (National Institute for Health and Clinical Excellence (NICE), 2008). There is evidence that the care provided before and after the operation is paramount to minimize the risk of surgical site infection. Sternal wound infections lengthen hospital stays (or prompt readmission) and carry a high mortality rate. In August 2009 a Manchester Hospital discovered a cluster of three patients with sternal wound infections. A review of clinical data for patients having cardiac surgery from 1 December 2008 and 9 October 2009 revealed an increased incidence of patients with sternal wound infections. The data did not reveal a significant problem, but one that should be kept under observation. During the investigation no single pathogen had been identified as responsible and no obvious source of environmental infection was identified. Implementing additional infection prevention and control practices helped the hospital team to improve the care given to patients. A host of factors, ranging from providing more information on wound care to patients, improving audit scores, and adhering to NICE guidelines, contributed to the reduction in this type of surgical site infection.     

Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients

OBJECTIVE: To estimate the magnitude of association between intraoperative hyperglycemia and perioperative outcomes in patients who underwent cardiac surgery. PATIENTS AND METHODS: We conducted a retrospective observational study of consecutive adult patients who underwent cardiac surgery between June 10, 2002, and August 30, 2002, at the Mayo Clinic, a tertiary care center in Rochester, Minn. The primary independent variable was the mean intraoperative glucose concentration. The primary end point was a composite of death and infectious (sternal wound, urinary tract, sepsis), neurologic (stroke, coma, delirium), renal (acute renal failure), cardiac (new-onset atrial fibrillation, heart block, cardiac arrest), and pulmonary (prolonged pulmonary ventilation, pneumonia) complications developing within 30 days after cardiac surgery. RESULTS: Among 409 patients who underwent cardiac surgery, those experiencing a primary end point were more likely to be male and older, have diabetes mellitus, undergo coronary artery bypass grafting, and receive insulin during surgery (P< or =.05 for all comparisons). Atrial fibrillation (n=105), prolonged pulmonary ventilation (n=53), delirium (n=22), and urinary tract infection (n=16) were the most common complications. The initial, mean, and maximal intraoperative glucose concentrations were significantly higher in patients experiencing the primary end point (P<.01 for all comparisons). In multivariable analyses, mean and maximal glucose levels remained significantly associated with outcomes after adjusting for potentially confounding variables, including postoperative glucose concentration. Logistic regression analyses indicated that a 20-mg/dL increase in the mean intraoperative glucose level was associated with an increase of more than 30% in outcomes (adjusted odds ratio, 1.34; 95% confidence Interval, 1.10-1.62). CONCLUSION: Intraoperative hyperglycemia is an independent risk factor for complications, including death, after cardiac surgery.     

冠状动脉旁路术中不同旁路材料的应用体会

目的 :总结冠状动脉旁路移植术中目前几种常用旁路材料的临床应用。方法 :2 0 0 0年 1月～ 2 0 0 2年 3月连续 5 6例行冠状动脉旁路移植术 ,旁路材料包括左乳内动脉 (5 6根 )、游离右乳内动脉 (2 1根 )、桡动脉 (3 2根 )和大隐静脉(4 3根 )。回顾分析不同旁路材料的手术结果。结果 :桡动脉移植后旁路血管“线样征”1例 ;无胸骨、前臂并发症 ;下肢切口感染 2例 ,均为糖尿病、大体重患者 ,治疗后痊愈 ;死亡 3例 ,与旁路材料无关 (非体外循环手术因循环状态不稳死亡 1例 ,鱼精蛋白过敏 1例 ,顽固性心律失常 1例 )。结论 :注意旁路材料的取制技巧 ,针对不同病变冠脉血管选取应用不同旁路血管 ,以及术后及时监护处理是保证良好手术结果的关键     

再生氧化纤维素在严重骨质疏松体外循环手术胸骨止血中的作用

背景：严重骨质疏松患者正中开胸胸骨出血较多,尤其是体外循环下手术存在凝血功能障碍,更加重了术中及术后出血。目的：与常规胸骨止血材料骨蜡对比,观察再生氧化纤维素在减少严重骨质疏松患者体外循环术后胸骨出血和预防胸骨切口感染中的作用。方法：84例行正中开胸体外循环心脏手术的严重骨质疏松患者,随机分成2组。再生氧化纤维素组胸骨创面及骨髓腔内填充覆盖再生氧化纤维素,对照组常规应用医用骨蜡。记录两组术后1d引流量、总引流量、拔引流管时间、总输血量、切口拆线时间、术后持续发热时间、平均住院时间及术后胸骨切口愈合情况,出院随访6个月。结果与结论：两组术后1d引流量、总引流量、拔引流管时间、总输血量及平均住院时间差异有显著性意义（P〈0.05）,再生氧化纤维素组更有优势。随访6个月中,再生氧化纤维素组未出现胸骨切口排出异物情况,对照组中有4例出现骨蜡排出。提示再生氧化纤维素可应用于严重骨质疏松患者体外循环后胸骨止血,近远期疗效确切,并在胸骨感染方面具有一定预防作用。     

Coronary artery disease in women

Cardiovascular disease is the number one cause of death in American women over age 40. Following menopause, the risk for coronary artery disease (CAD) in women is the same as for men. In addition, the major factors that place men at risk are the same for women. However, differences exist in the presentation of symptoms, the ease of diagnosis of CAD, and the morbidity and mortality rates following myocardial infarction (MI), coronary artery bypass surgery, and angioplasty. Because of role differences in men and women, more attention must be paid to developing successful health-promoting and life-style-change strategies in women of all ages.     

Sternal wound care to prevent infections in adult cardiac surgery patients

Sternal wound infection post-cardiac surgery is a serious complication that can lead to increased length of stay, substantial financial impact, and increased mortality. The occurrence of sternal wound infections has been reported from 0.4% to 4% of postoperative cardiac surgeries. It is imperative that every heart surgery program implements the best practice to prevent the detrimental effects of sternal wound infections. In an effort to improve the cardiothoracic (CT) surgery program in a community hospital, a decision was made to create a specialty floor including specialized nurses to care for open-heart surgery patients. In October 2010, a group of these nurses formed a working committee to explore ways to improve the overall care of our CT surgery patients. A vision and purpose for this committee were identified: (1) update and improve practice for CT surgery patients utilizing evidence-based standards, (2) successfully disseminate this information to all staff caring for the CT surgery patients, and (3) evaluate the impact of any practice changes on patient outcomes. An initial focus for the committee was to standardize sternal wound care among all staff members on the cardiovascular floors, cardiac care unit, and progressive care unit.     

Bilateral internal mammary artery grafting

The superiority of the left internal mammary artery over the saphenous vein graft led many surgeons to adopt bilateral internal mammary artery (BIMA) as a good surgical option for further improving late outcome of patients undergoing myocardial revascularization. However, routine use of BIMA was limited by some potential drawbacks: the increase of deep sternal wound problems, especially in diabetic patients; the shortness of right internal mammary artery (RIMA), which limited its utilization as an in situ graft; the low patency rate if grafted to the right coronary artery; and the longer operative time. The skeletonization of the internal mammary artery along with a better glucose control in diabetic patients significantly reduced the incidence of deep sternal problems. Another problem to solve was finding the optimal target of the RIMA. The general consensus is that RIMA appears to be more efficient if grafted to the lateral wall. The Y or T configuration of double mammary arteries could be more helpful to reach the lateral target vessels. Finally, recent reports clearly demonstrate the superiority of BIMA over single internal mammary artery in terms of survival or quality of life. The latter finding has also been reported in diabetic patients.     

Bilateral internal mammary artery grafting

The superiority of the left internal mammary artery over the saphenous vein graft led many surgeons to adopt bilateral internal mammary artery (BIMA) as a good surgical option for further improving late outcome of patients undergoing myocardial revascularization. However, routine use of BIMA was limited by some potential drawbacks: the increase of deep sternal wound problems, especially in diabetic patients; the shortness of right internal mammary artery (RIMA), which limited its utilization as an in situ graft; the low patency rate if grafted to the right coronary artery; and the longer operative time. The skeletonization of the internal mammary artery along with a better glucose control in diabetic patients significantly reduced the incidence of deep sternal problems. Another problem to solve was finding the optimal target of the RIMA. The general consensus is that RIMA appears to be more efficient if grafted to the lateral wall. The Y or T configuration of double mammary arteries could be more helpful to reach the lateral target vessels. Finally, recent reports clearly demonstrate the superiority of BIMA over single internal mammary artery in terms of survival or quality of life. The latter finding has also been reported in diabetic patients.