Mediastinitis after coronary artery bypass grafting: the effect of vacuum‐assisted closure versus traditional closed drainage on survival and re‐infection rate

Mediastinitis is treated with either vacuum‐assisted closure (VAC) or traditional closed drainage (TCD) with irrigation. The aim of the study was to determine the effect of the two treatments on mortality and re‐infection rate in a source population, using 21 314 consecutive patients undergoing isolated coronary artery bypass grafting (CABG) from January 1997 to October 2010. Median observation time was 2·9 years in the VAC group and 8·0 years in the TCD group. The epidemiological design was of an exposed (VAC, n = 64) versus non‐exposed (TCD, n = 66) cohort with two endpoints: (1) mortality and (2) failure of sternal wound healing or re‐infection. The crude effect of treatment technique versus endpoint was estimated by univariate analysis. Stratification analysis by the Mantel–Haenszel method was performed to quantify confounders and to pinpoint effect modifiers. Adjustment for confounders was performed using Cox regression analysis. Mediastinitis was diagnosed 6–105 (median 14) days after primary operation in the VAC group and 13 (5–29) days in the TCD group. There was no difference between groups in long‐term survival. Failure of sternal wound healing or re‐infection occurred less frequently in the VAC group (6%) than in the TCD group (21%; relative risk = 0·29, 95% CI = 0·06–0·88, P = 0·01). There are concerns for increase in right ventricle rupture in VAC compared with TCD. There was no difference in survival after VAC therapy and TCD therapy of post‐CABG mediastinitis. Failure of sternal wound healing or re‐infection was more common after TCD therapy.     

Mediastinitis after coronary artery bypass grafting increases the incidence of left internal mammary artery obstruction

Mediastinitis after coronary artery bypass grafting (CABG) gives a longstanding chronic inflammation and has a detrimental negative effect on long‐term survival. For this reason, we aimed to study the effect of mediastinitis on graft patency after CABG. The epidemiologic design was of an exposed (mediastinitis, n = 41) versus non‐exposed (non‐mediastinitis, controls, n = 41) cohort with two endpoints: (i) obstruction of saphenous vein grafts (SVG) and (ii) obstruction of the internal mammary artery (IMA) grafts. The graft patency was evaluated with coronary CT‐angiography examination at a median follow‐up of 2·7 years. The number of occluded SVG in the mediastinitis group was 18·9% versus 15·5% in the control group. Using generalized estimating equations model with exchangeable matrix, and confounding effect of ischaemic time and patients age, we found no significant association between presence of mediastinitis and SVG obstruction [rate ratio (RR) = 0·96, 95% CI (0·52–2·67), P = 0·697]. The number of occluded IMA grafts was 10·5% in the mediastinitis group and 2·4% in the control group. Using the Poisson regression model, we estimated RR = 5·48, 95% CI (1·43–21·0) and P = 0·013. There was a significant association between mediastinitis and IMA graft obstruction, when controlling for the confounding effect of ischaemic time, body mass index, presence of diabetes mellitus and the number of diseased vessels. Presence of mediastinitis increases the risk of IMA graft obstruction. This may confirm the importance of inflammation as a major contributor to the pathogenesis of atherosclerosis and explain the negative effect of mediastinitis on a long‐term survival.     

升主动脉心外膜超声成像在冠状动脉旁路移植术中的价值

目的探讨心外膜超声技术在冠状动脉旁路移植术中检查升主动脉的临床意义.方法应用心外膜超声探头在45例非体外循环旁路移植术中对升主动脉进行检查,判定是否形成粥样斑块及其程度,同时与术者触诊所得出的结果进行比较.术者根据斑块部位及程度改变手术方法及方式.结果45例中正常20例,动脉粥样斑块形成25例,其中轻度9例、中度10例、重度6例.心外膜超声技术对升主动脉粥样斑块的检出率明显高于触诊检查.所有病例未发生围手术期中风.结论应用心外膜超声技术可以较触诊更敏感地发现升主动脉粥样斑块形成,可以降低围手术期中风的发生率,具有重要的临床价值.     

Prevalence of dental erosion in children: a national survey

Arnadottir IB, Holbrook WP, Eggertsson H, Gudmundsdottir H, Jonsson SH, Gudlaugsson JO, Saemundsson SR, Eliasson ST, Agustsdottir H. Prevalence of dental erosion in children: a national survey. Community Dent Oral Epidemiol 2010; 38: 521–526. © 2010 John Wiley & Sons A/S Abstract – Objectives:  To measure the prevalence of dental erosion in permanent teeth in Iceland as part of the National Oral Health Survey. Methods:  A representative, nationwide sample of 2251 Icelandic children, 20% of those aged 6, 12 and 15 year, was examined. Dental erosion was recorded for all erupted permanent teeth and graded using the modified scale of Lussi. Results:  Erosion was not seen in the permanent teeth of six‐year‐olds, but was present in 15.7% of 12‐year‐olds, more frequently in boys than girls (19.9% boys, 11.0% girls; P < 0.001). Among 15‐year‐olds, dental erosion was seen among 30.7% of subjects (38.3% boys, 22.7% girls; P < 0.001). Severity of erosion was mostly scored as grade I, with only 5.5% of 15‐year‐olds scored as grade II, mostly on tooth 46 (4.3%) and 36 (4.2%). For 12‐year‐olds, 0.9% had erosion scores of grade II mostly on tooth 46 (0.8%) and 36 (0.7%). No subjects had erosion of grade III. The most common clinical manifestation of erosion was the appearance of cup‐like lesions on the cusps of lower first molars. Conclusions: Dental erosion was frequently present by the age of 12; the prevalence doubled by age 15 and was seen almost twice as often among boys than girls. Teeth most frequently showing signs of erosion were the lower first molars. The rapidly growing prevalence of erosion demonstrated by this nationwide survey emphasizes the need for further research into the aetiology of erosion and possible methods of preventing and treating this emerging dental problem.     

The importance of intraoperative angiographic findings for predicting long-term patency in coronary artery bypass operations

BACKGROUND: The quality of anastomosis is the cornerstone in coronary artery bypass operations. Intraoperative coronary angiography confirms graft patency with the possibility to revise graft failure. The aim of this study was to describe the lesions found at "on-table" angiography, and to evaluate the significance of these immediate angiographic findings for the long-term patency. METHODS: A total of 57 grafts (42 left internal mammary artery grafts and 15 saphenous vein grafts) in 45 patients who underwent off-pump coronary artery bypass operations were included. On-table angiography was carried out with fixed angiographic equipment installed in the operating room. Follow-up angiographies were performed at 3 months and at 12 months. RESULTS: The most frequent finding in an on-table angiogram was spasm, which was not present at follow-up. Out of nine kinks, only one developed into a significant stenosis at follow-up. Of 44 grafts that were normal on-table, 37 (84%) were normal at the follow-up. Of 11 grafts with significant lesions on-table, eight (73%) were normal at the follow-up. Five percent of the grafts were revised because of the on-table angiography. CONCLUSIONS: On-table angiograms can be occasionally difficult to interpret because not all findings are important for later patency. Optimal results on-table predict good long-term results with a negative predictive value of 0.84, whereas significant lesions on-table have less impact on the follow-up results because the positive predictive value was only 0.38.     

Leg wound closure after saphenous vein harvesting in patients undergoing coronary artery bypass grafting: a prospective randomized study comparing intracutaneous,transcutaneous and zipper techniques

OBJECTIVE: Two prospective randomized studies were undertaken to compare different suture closure techniques with respect to postoperative wound infection rates and cosmetic results after saphenous vein harvesting in patients undergoing coronary artery bypass surgery. DESIGN: A total of 166 patients were included in the first study, in which 85 had their leg wounds closed with transcutaneous and 81 with intracutaneous suture. In the second study, 168 patients were selected to a non-invasive surgical zipper (n = 78) or intracutaneous suture (n = 90). RESULTS: In the first study the overall infection rate was 20.5%, 17.6% in the transcutaneous group compared with 23.5% in the intracutaneous group (p = 0.35). In the second study the infection rate was 19.3%, 15.3% in the zipper group vs 23.3% in the intracutaneous group (p = 0.20). On a cosmetic scale from 1 to 10, an average score of 8.0 was obtained in the percutaneous (p.c.) group vs 8.3 in the intracutaneous (i.c.) group (p = 0.35), and 9.0 in the zipper group vs 8.4 in the i.c. group (p = 0.003). CONCLUSION: The incidence of leg wound infection after saphenous vein harvesting in coronary artery bypass graft surgery is high. The zipper closing method may give a lower infection rate and a better cosmetic result compared with the intracutaneous suture.     

Failure to seek needed medical care: results from a national health survey of Icelanders

The study focuses on access to outpatient medical care in Iceland--a socialized health care system. As in other systems of this sort, equal access to needed services (equity) is a fundamental principle. Despite governmental claims that access to health services is "easy" and "roughly equal", the study indicates substantial and rather extensive variations in equity of care. More specifically, younger individuals, the non-widowed, the economically troubled, individuals with inflexible daily schedules, the chronically ill, those who had incurred high out-of-pocket costs relative to their family income, and those who didn't have a physician care discount card, were more likely than others to postpone or cancel an MD visit they thought they needed. Furthermore, younger age, economic troubles, chronic medical conditions, no family physician, and no physician care discount card, were all related to under-utilization, based on medical specialist criteria of recommended medical care for symptoms. Although the results show that access problems originate in part outside the health care system, they also suggest revision of current health policy, in order to adequately address existent inequities in service delivery.     

Intraoperative and intermediate-term angiographic results of coronary artery bypass surgery with Symmetry proximal anastomotic device

OBJECTIVE: The objective of this study was to investigate the patency in saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices or with a traditional suture technique. METHODS: Forty-six patients underwent coronary artery bypass grafting without cardiopulmonary bypass by using one thoracic graft and one or more saphenous vein grafts. Grafts were attached to the aorta with a Symmetry connector (St Jude Medical, Inc, St Paul, Minn) in 23 patients, and partial occlusion of the aorta and sutured anastomoses were used in 23 other patients. Grafts were studied intraoperatively with transit time flowmetry and angiography and revised if necessary. Angiography was repeated after 3 to 5 months. RESULTS: Intraoperative graft patency did not differ between the 2 groups. Follow-up angiography demonstrated excellent thoracic graft patency. Vein graft patency decreased to 50% in the Symmetry group, whereas it was 90% in the suture group ( P = .01). Twenty-five percent of the Symmetry grafts had significant stenosis in the connector. CONCLUSION: Saphenous vein grafts anastomosed to aorta with the Symmetry proximal connector have low intermediate patency compared with those with traditionally sutured anastomoses. We do not recommend the routine use of this device in coronary artery bypass operations.     

Complement activation and cytokine and chemokines release during mediastinitis

BACKGROUND: Mediastinitis after open heart operation is an infrequent, but life-threatening complication with a reported incidence rate between 1% and 4%. Hospital mortality is estimated at 10% to 35%. The aim of the present work was to study the systemic inflammatory reaction as judged by complement activation and cytokine and chemokines release in patients with mediastinitis after open heart operation. METHODS: Seven patients with clinical signs of mediastinitis were included. Three patients had undergone coronary artery bypass grafting, whereas 4 patients had combined coronary artery bypass grafting, valve replacement, or valvuloplasty. Blood samples were drawn before induction of anesthesia and at the time of reoperation, and thereafter daily during the hospital stay. Controls comprised similar patients with an uneventful postoperative course. RESULTS: The terminal SC5b-9 complement complex concentration in the mediastinitis patients was substantially higher compared with the controls (p < 0.001), and the terminal SC5b-9 complement complex values showed no overlap between the two groups. Interleukin-8, stromal cell-derived factor-1alpha and IL-6 concentrations were also significantly higher in the mediastinitis group than in the control group (p < 0.001), but with considerable overlap between the groups. Interleukin-1beta, interleukin-10, and monocyte chemoattractant protein-1 concentrations were slightly higher in the mediastinitis group, and no differences were seen for the tumor necrosis factor-alpha. CONCLUSIONS: During mediastinitis, the complement is activated and the cytokines and chemokines, interleukin-6, interleukin-8, and stromal cell-derived factor-1alpha are released. These proteins may be involved in the pathogenesis of this complication. Terminal SC5b-9 complement complex may be an indicator to discriminate mediastinitis patients from those with uneventful course.