Advances in Clinical and Experimental Medicine

Title abbreviation: Adv Clin Exp Med
5-Year IF – 2.0, IF – 1.9, JCI (2024) – 0.43
Scopus CiteScore – 4.3
Q1 in SJR 2024, SJR score – 0.598, H-index: 49 (SJR)
ICV – 161.00; MNiSW – 70 pts
Initial editorial assessment and first decision within 24 h

ISSN 1899–5276 (print), ISSN 2451-2680 (online)
Periodicity – monthly

Download original text (EN)

Advances in Clinical and Experimental Medicine

2019, vol. 28, nr 7, July, p. 913–922

doi: 10.17219/acem/94154

Publication type: original article

Language: English

Download citation:

  • BIBTEX (JabRef, Mendeley)
  • RIS (Papers, Reference Manager, RefWorks, Zotero)

Complications in cardiac surgery: An analysis of factors contributing to sternal dehiscence in patients who underwent surgery between 2010 and 2014 and a comparison with the 1990–2009 cohort

Mariusz J. Listewnik1,A,B,C,D,E,F, Tomasz Jędrzejczak1,A,E,F, Krzysztof Majer1,B,C, Aleksandra Szylińska1,B,C, Anna Mikołajczyk1,B,C, Krzysztof Mokrzycki1,E,F, Elżbieta Górka1,B, Mirosław Brykczyński1,E

1 Department of Cardiac Surgery, Pomeranian Medical University in Szczecin, Poland

Abstract

Background. Sternal dehiscence is a serious postoperative complication of cardiac surgery observed in 0.2–5% of procedures performed by median sternotomy.
Objectives. Assessment of factors, including the method of sternum closure, which may affect the incidence of this complication.
Material and Methods. A total of 5,152 consecutive patients undergoing surgery with median sternotomy access in the Cardiac Surgery Department of the Pomeranian Medical University between 2010 and 2014 were included in the study. The analysis centered on cases of sternal dehiscence, which occurred in 45 patients (0.9%).
Results. Factors such as age (p < 0.05), body mass (p < 0.005) and coronary artery bypass surgery (CABG) (p < 0.005) were found to be significant risk factors. Diabetes and chronic obstructive pulmonary disease (COPD) also had an impact on an increased risk of sternal dehiscence (p < 0.006 and p < 0.015). However, the differences were only significant in the whole study group. Apart from CABG, the type of operation did not affect the incidence of dehiscence. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass index (BMI) (odds ratio (OR): 2.1; p < 0.019), diabetes (OR: 2.4; p < 0.004), COPD (OR: 2.7; p < 0.016), and redo procedure (OR: 3.0; p < 0.014). There were no significant differences in postoperative mortality between these groups – 6.7% in the group with sternal dehiscence and 3.9% in the group without dehiscence.
Conclusion. Introducing a more durable sternum stabilization method with 8+ loops helped to improve conditions for bone union and reduced the risk of dehiscence. Therefore, we suggest that centers which still use 6-loop sternal closure should consider shifting to a stronger technique.

Key words

risk factors, cardiac surgery, median sternotomy

References (30)

  1. Almdahl SM, Halvorsen P, Veel T, Rynning SE. Avoidance of noninfectious sternal dehiscence: Figure-of-8 wiring is superior to straight wire closure. Scand Cardiovasc J. 2013;47(4):247–250.
  2. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: A comprehensive review. Eur J Cardiothorac Surg. 2002;21(5):831–839.
  3. Narang S, Banerjee A, Satsangi DK, Geelani MA. Sternal weave in high-risk patients to prevent noninfective sternal dehiscence. Asian Cardiovasc Thorac Ann. 2009;17(2):167–170.
  4. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy. Thorac Cardiovasc Surg. 2000;48(1):1–8.
  5. Listewnik M, Kazimierczak A, Mokrzycki K. Powikłania w kardiochirurgii: rozejścia mostka po pośrodkowej sternotomii. Analiza wyników 14,171 operacji kardiochirurgicznych wykonanych w latach 1990–2009. Pomeranian J Life Sci. 2015;61(4):383–388.
  6. Listewnik MJ, Sielicki P, Mokrzycki K, Biskupski A, Brykczyński M. The use of vacuum-assisted closure in purulent complications and difficult-to-heal wounds in cardiac surgery. Adv Clin Exp Med. 2015;24(4):643–650.
  7. Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. The median sternal incision in intracardiac surgery with extracorporeal circulation: A general evaluation of its use in heart surgery. Surgery. 1957;42(4):753–761.
  8. Shumacker HB, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg. 1963;86(3):384–387.
  9. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation. 1995;92(8):2245–2251.
  10. Zalewska-Adamiec M, Bachórzewska-Gajewska H, Tomaszuk-Kazberuk A, et al. Wpływ otyłości na rokowanie i ryzyko powikłań u pacjentów z chorobą pnia lewej tętnicy wieńcowej leczonych kardiochirurgicznie. Pol Przegl Kardiol. 2012;14(1):29–36.
  11. Harjula A, Jarvinen A. Postoperative median sternotomy dehiscence. Scand J Thorac Cardiovasc Surg. 1983;17(3):277–281.
  12. Shafir R, Weiss J, Herman O, Cohen N, Stern D, Igra Y. Faulty sternotomy and complications following median sternotomy. J Thorac Cardiovasc Surg. 1988;96(2):310–313.
  13. Bitner M, Jaszewski R. Rozejścia mostka po operacjach w krążeniu pozaustrojowym w umiarkowanej hipotermii (lata 1987–1994) i w normotermii ogólnej (lata 1995–2000). Clin Exp Med Lett. 2005;46(3):47–50.
  14. Gualis J, Flórez S, Tamayo E, Alvarez FJ, Castrodeza J, Castaño M. Risk factors for mediastinitis and endocarditis after cardiac surgery. Asian Cardiovasc Thorac Ann. 2009;17(6):612–616.
  15. Wouters R, Wellens F, Vanermen H, De Geest R, Degrieck I, De Meerleer F. Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. Tex Heart Inst J. 1994;21(3):183–188.
  16. Lemaignen A, Birgand G, Ghodhbane W, et al. Sternal wound infection after cardiac surgery: Incidence and risk factors according to clinical presentation. Clin Microbiol Infect. 2015;21:674.e11–674.e18.
  17. Kalush SL, Cherukuri RB, Teller D, Watson C, Murphy B, Shaheen S. Bilateral mammary artery bypass and sternal dehiscence. A favorable outcome. Am Surg. 1990;56(8):487–493.
  18. Vymazal T, Horácek M, Durpekt R, Hladíková M, Cvachovec K. Is allogeneic blood transfusion a risk factor for sternal dehiscence following cardiac surgery? A prospective observational study. Int Heart J. 2009;50(5):601–607.
  19. Abid Q, Podila SR, Kendall S. Sternal dehiscence after cardiac surgery and ACE type I inhibition. Eur J Cardiothorac Surg. 2001;20(1):203–204.
  20. El Oakley RM, Wright JE. Postoperative mediastinitis: Classification and management. Ann Thorac Surg. 1996;61(3):1030–1036.
  21. Bitkover CY, Gardlund B. Mediastinitis after cardiovascular operations: A case-control study of risk factors. Ann Thorac Surg. 1998;65(1):36–40.
  22. Aykut K, Celik B, Acıkel U. Figure-of-eight versus prophylactic sternal weave closure of median sternotomy in diabetic obese patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 2011;92(2):638–641.
  23. Levin LS, Miller AS, Gajjar AH, et al. An innovative approach for sternal closure. Ann Thorac Surg. 2010;89(6):1995–1999.
  24. Okutan H, Tenekeci C, Kutsal A. The reinforced sternal closure system is reliable to use in elderly patients. J Card Surg. 2005;20(3):271–273.
  25. Schimmer C, Reents W, Elert O. Primary closure of median sternotomy: A survey of all German surgical heart centers and a review of theliterature concerning sternal closure technique. Thorac Cardio­vasc Surg. 2006;54(6):408–413.
  26. Schimmer C, Reents W, Berneder S, et al. Prevention of sternal dehiscence and infection in high-risk patients: A prospective randomized multicenter trial. Ann Thorac Surg. 2008;86(6):1897–1904.
  27. Totaro P, Lorusso R, Zogno M. Reinforced sternal closures for prevention of sternal dehiscence in high risk patients. J Cardiovasc Surg (Torino). 2001;42(5):601–603.
  28. Bottio T, Rizzoli G, Vida V, Casarotto D, Gerosa G. Double crisscross sternal wiring and chest wound infections: A prospective randomized study. J Thorac Cardiovasc Surg. 2003;126(5):1352–1356.
  29. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007–1021.
  30. Pouwels S, Hageman D, Gommans LNM, et al. Preoperative exercise therapy in surgical care: A scoping review. J Clin Anesth. 2016;33(9):476–490.
© Wroclaw Medical University