Preoperative risk stratification of deep sternal wound infection after coronary surgery

Abstract

Objective:To develop a risk score for deep sternal wound infection (DSWI) after isolated coronary artery bypass grafting (CABG).Design:Multicenter, prospective study.Setting:Tertiary-care referral hospitals.Participants:The study included 7,352 patients from the European multicenter coronary artery bypass grafting (E-CABG) registry.Intervention:Isolated CABG.Methods:An additive risk score (the E-CABG DSWI score) was estimated from the derivation data set (66.7% of patients), and its performance was assessed in the validation data set (33.3% of patients).Results:DSWI occurred in 181 (2.5%) patients and increased 1-year mortality (adjusted hazard ratio, 4.275; 95% confidence interval [CI], 2.804–6.517). Female gender (odds ratio [OR], 1.804; 95% CI, 1.161–2.802), body mass index ≥30 kg/m2 (OR, 1.729; 95% CI, 1.166–2.562), glomerular filtration rate <45 mL/min/1.73 m2 (OR, 2.410; 95% CI, 1.413–4.111), diabetes (OR, 1.741; 95% CI, 1.178–2.573), pulmonary disease (OR, 1.935; 95% CI, 1.178–3.180), atrial fibrillation (OR, 1.854; 95% CI, 1.096–3.138), critical preoperative state (OR, 2.196; 95% CI, 1.209–3.891), and bilateral internal mammary artery grafting (OR, 2.088; 95% CI, 1.422–3.066) were predictors of DSWI (derivation data set). An additive risk score was calculated by assigning 1 point to each of these independent risk factors for DSWI. In the validation data set, the rate of DSWI increased along with the E-CABG DSWI scores (score of 0, 1.0%; score of 1, 1.8%; score of 2, 2.2%; score of 3, 6.9%; score ≥4: 12.1%; P < .0001). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed that the E-CABG DSWI score performed better than other risk scores.Conclusions:DSWI is associated with poor outcome after CABG, and its risk can be stratified using the E-CABG DSWI score.Trial registration:clinicaltrials.gov identifier: NCT02319083

<p>Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia?</p>

“…This suggests that the percentage of patients with unbalanced diabetes mellitus or who did not stop smoking before the surgical procedure could modify the estimation of the impact of diabetes mellitus and smoking on the development of SWI across studies. Because obesity cannot be corrected quickly before elective CABG, we presume that the independent association between obesity and SWI that we and others worldwide have observed remains relevant after CABG, 30,31 but not after valve surgery. 32 In addition to SWI, preoperative anaemia has also previously been associated with death, stroke, atrial fibrillation or ARF after heart surgery.…”

Does the anthropometric profile influence infection morbidity after coronary artery bypass grafting?

“…Independent predictors of any infection morbidity identified in this paper have support in the literature. Female gender, age >60 years, duration of cardiopulmonary bypass >120 min, preoperative myocardial infarction <30 days, diabetes mellitus, ejection fraction <48%, and the need for blood transfusion 23,24 . The anthropometric profile was not significantly associated with infection ( p = .12), after adjusting for possible confounders.…”

Why and how to achieve total arterial revascularisation in coronary surgery

“…The principle risk of BIMA is a higher rate of deep sternal wound infection. The literature is vast with considerable debate; however, large-scale or meta-analyses indicate a consistent finding that the rate is approximately double that of single IMA, higher in diabetics and obese females and possibly lower with skeletonised IMA [53][54][55][56] . Logically, harvesting the IMA by any method substantially reduces the blood supply to one side of the sternum, and any difference between harvest techniques is not likely to be substantial.…”

“…For these left coronary vessel targets, the presence of a patent IMA graft in close proximity to the ascending aorta results poses a significant risk of inadvertent injury during redo surgery. Additionally, the meta-analysis data would suggest that, on balance, the risk of deep sternal wound infection with bilateral compared to unilateral IMA harvest roughly doubles [53][54][55][56] . The free graft is commonly believed to confer a lower patency compared to the in situ graft.…”