Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

Background Bilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels. Methods A propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections. Results A total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577). Conclusions In-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

1097 17 Years of Treating Deep Sternal Wound Infections at A Single Institution: Outcomes and Lessons Learned

Introduction Deep sternal wound infections (DSWI) are a serious complication following cardiac surgery that comprise of any infection penetrating the subcutaneous tissue of the sternum. DSWI have been found to increase mortality and worsen prognostic outcomes following surgery. Method We conducted a retrospective cohort study using hospital e-records from 2000 to 2017 of all adult patients operated on with a median sternotomy at our institution. Univariate and multivariate analysis along with mortality and Kaplan-Meier survival curves compared the DSWI population against the remaining study population, using SPSS-25 software. Results Of 15521 total patients in the study, 145 (0.9%) suffered a DSWI. Variables that were associated with DSWI included age at operation (p = 0.019), gender (p = 0.007), BMI (p = 0.001), diabetes (p < 0.0001), renal disease (p = 0.008), operative urgency (p = 0.007), type of operation (p = 0.02), Euroscore (p = <0.0001), bypass-time (p = 0.038) and crossclamp-time (p = 0.008). A logistic regression encompassing significant variables revealed that gender (p = 0.031 CI 1.45-1.96), BMI (p < 0.0001 CI 1.03-1.10), diabetes (p = 0.007 CI 1.20-3.67) and type of operation (p = 0.018 CI 1.23-1.87) remained significant when covariate contribution was eliminated. DSWI subgroup mortality was insignificant at 30 days (3.4%vs2.9%, p = 0.68) but significantly worse at 90 days (8.3%vs3.7%, p = 0.004) and at 1 year (17.2%vs5.4%, p < 0.0001). Kaplan-Meier analysis depicted a significantly worse survival distribution for the DSWI population compared to rest of study (Log-Rank<0.05). Conclusions At our centre, DSWI are attributable to certain modifiable and set demographics and contribute heavily to medium-term mortality. A better understanding of DSWI risk factors may pinpoint those at risk and benefit the multidisciplinary team to ultimately reduce the rate of DSWI.

Aortic Pseudoaneurysm Following Aortic Valve Replacement Complicated by Sternal Wound Infection

Pseudoaneurysm of the ascending aorta is a rare complication of cardiac surgery occurring in less than 0.5% of cases. Deep sternal wound infections (DSWI) increase the likelihood of aortic pseudoaneurysm. An ascending aortic pseudoaneurysm has high morbidity and the mortality rate has ranged from 29%-46% in the medical literature. We report a complex patient who underwent an AVR at an outside hospital complicated by DSWI requiring pectoral flap coverage. Months later, he was transferred to our institution with acute swelling of his sternum, diagnosed as massive aortic pseudoaneurysm originating from the cannulation site.

Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach

Background Pediatric sternal wound complications (SWCs) include sterile wound dehiscence (SWD) and superficial/deep sternal wound infections (SSWI/DSWI), and are generally managed by repetitive debridement and surgical wound approximation. Here, we report a novel nonsurgical management strategy of pediatric sternotomy wound complications, using serial noninvasive wound approximation technique combined with single-use negative pressure wound therapy (PICO) device. Methods Nine children with SWCs were managed by serial approximation with adhesive skin tapes and serial PICO device application. Thorough surgical debridement or surgical approximations were not performed. Results Three patients were clinically diagnosed as SWD, two patients as SSWI, and four patients as DSWI. None of the wounds demonstrated apparent mediastinitis or bone destructions. PICO device was applied at 16.1 days (range: 6–26 days) postoperatively, together with serial wound approximation by skin tapes. The average duration of PICO use was 16.9 days (range: 11–29 days) and the wound approximation was achieved in all patients. None of the patients underwent aggressive surgical debridement or invasive surgical approximation by sutures. Conclusion We report our successful management of selected pediatric SWCs, using serial noninvasive wound approximation technique combined with PICO device.

Body Mass Index (BMI) and Its Influence on the Cardiovascular and Operative Risk Profile in Coronary Artery Bypass Grafting Patients: Impact of Inflammation and Leptin

Background. Obesity is related to coronary artery disease (CAD) and worse outcomes in coronary artery bypass graft (CABG) patients. Adipose tissue itself is an endocrine organ that secretes many humoral mediators, such as adipokines, which can induce or reduce inflammation and oxidative stress. Objectives. We investigate the relationship between the body mass index (BMI), inflammation, and oxidative stress by measuring serum levels of leptin, interleukin-6, and 3-nitrotyrosine in CABG patients and correlate their levels to the cardiovascular and operative risk profiles. Methods and Results. 45 men (<75 years) with a median BMI of 29 (21-51) kg/m2, who were diagnosed with CAD and scheduled for elective CABG, were included after applying the following exclusion criteria: prior myocardial infarction, reoperation, female gender, and smoking. Patients’ blood samples were taken preoperatively. Several markers were measured. We found significant correlations between leptin and BMI p<0.0001 as well as between leptin and 3-nitrotyrosine p=0.006. Interleukin-6 was correlated with C-reactive protein p<0.0001 and with the incidence of insulin-dependent diabetes mellitus p=0.036, arterial hypertension p=0.044, reduced left ventricular function p=0.003, and severe coronary calcification p=0.015. It was also associated with significantly longer extracorporeal bypass time p=0.009. Postoperative deep sternal wound infections could be predicted by a higher BMI p=0.003 and leptin level p=0.001. Conclusions. There seems to be a correlation between inflammatory processes and cardiovascular morbidity in our cohort. Further, the incidence of deep sternal wound infections is related to a higher BMI and leptin serum level.