Original article
Epidemiology of Deep Sternal Wound Infection in Cardiac Surgery

https://doi.org/10.1053/j.jvca.2009.02.007Get rights and content

Objectives

The aim of this study was to investigate the incidence and predictors of deep sternal wound infection (DSWI) in a contemporary cohort of patients undergoing cardiac surgery. The early and late outcomes of patients with this complication also were analyzed.

Design

A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively.

Setting

A university hospital (single institution).

Participants

Five thousand seven hundred ninety-eight patients who underwent cardiac surgery between January 1998 and December 2005 including isolated coronary artery bypass graft (CABG) (n = 2,749, 47%), single- or multiple-valve surgery (n = 1,280, 22%), combined valve and CABG procedures (n = 934, 16%), and surgery involving the ascending aorta or the aortic arch (n = 835, 15%).

Interventions

None.

Measurements and Main Results

The overall incidence of DSWI was 1.8% (n = 106). The highest rate of DSWI occurred after combined valve/CABG surgery (2.4%, n = 22) and aortic procedures (2.4%, n = 19). Multivariate analysis revealed 11 predictors of DSWI: obesity (odds ratio [OR] = 2.2), previous myocardial infarction (OR = 2.1), diabetes (OR = 1.7), chronic obstructive pulmonary disease (OR = 2.3), preoperative length of stay >3 days (OR = 1.9), aortic calcification (OR = 2.7), aortic surgery (OR = 2.4), combined valve/CABG procedures (OR = 1.9), cardiopulmonary bypass time (OR = 1.8), re-exploration for bleeding (OR = 6.3), and respiratory failure (OR = 3.2). The mortality rate was 14.2% (n = 15) versus 3.6% (n = 205) in the control group (p < 0.001). One- and 5-year survival after DSWI were significantly decreased (72.4% ± 4.4% and 55.8% ± 5.6% v 93.8% ± 0.3% and 82.0% ± 0.6%, p < 0.001).

Conclusion

DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival.

Section snippets

Methods

From January 1998 to December 2005, 6,326 consecutive patients who underwent cardiac surgery at the authors' institution, were retrospectively analyzed. A total of 528 patients (ventricular-assist device implantation or heart transplantation, n = 221; thoracotomy approach for descending thoracic aortic surgery, n = 307) were excluded. The remaining 5,798 patients formed the study population.

The protocol was approved by the local institutional review board and is compliant with the Health

Results

A total of 5,798 patients with a mean age of 64 ± 14 years were included in this study. Sixty-two percent (n = 3,612) of patients were men. Patient demographics and distribution of risk factors are shown in Table 1. Surgical procedures included isolated CABG surgery (47%, n = 2,749), single- or multiple-valve surgery (22%, n = 1,280), combined valve/CABG procedures (16%, n = 934), and surgery involving the ascending aorta or the aortic arch (15%, n = 835). The median-predicted mortality by

Discussion

The reported incidence of DSWI has ranged from 0.5% to 6.8%.1, 7, 8 This variation may be explained by differences in study design (case control v retrospective observational studies), patient profile, type of surgical procedures performed, and definitions of DSWI. DSWI has been defined as bone-related infections with the need for surgical intervention,9, 10 but a number of studies also included superficial wound infections, consequently reporting a higher incidence of this complication.8, 11

Summary

Deep sternal infection has an incidence of 1.8% in the authors' practice. Improvements in surgical management using a staged approach with vacuum dressings have contributed to improved outcome, but mediastinitis still has a significant negative impact on long-term outcome. The most important patient-related independent risk factors for DSWI include obesity, diabetes, and aortic calcification. The main procedure-related independent risk factors identified were procedural complexity, CPB time,

References (27)

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