Sternal Wound Complications in Bilateral Internal Thoracic Artery Grafting: A Comparison of the Off-Pump Technique and Conventional Cardiopulmonary Bypass
Background. Sternal wound complication is a major concern in bilateral internal thoracic artery grafting. The purpose of this study was to assess whether avoiding cardiopulmonary bypass has beneficial effects with fewer wound complications in patients receiving bilateral internal thoracic artery grafting.
Methods. Retrospective review was performed using prospectively gathered data of 69 patients who had undergone elective coronary artery bypass grafting and received conventional pedicled bilateral internal thoracic artery grafting from December 2002 through April 2004 by the same surgical team. The patients were divided into 2 groups: those who underwent coronary artery bypass grafting without cardiopulmonary bypass (off-pump group, n = 41), and those who underwent coronary artery bypass grafting with cardiopulmonary bypass (CPB group, n = 28). Chart review and 3-month follow-up were obtained for all patients. These 2 groups were compared for sternal wound complications and preoperative, intraoperative, and postoperative variables.
Results. Deep sternal wound infection (SWI) was seen in 1 patient (2.4%), superficial SWI in 2 patients (4.8%), and sternal dehiscence in 1 patient (2.4%) in the off-pump group. Deep SWI was seen in no patients, superficial SWI in 2 patients (7.1%) and sternal dehiscence in 2 patients (7.1%) in the CPB group. No statistically significant difference in the frequency of occurrence of sternal complications was detected between the 2 study groups.
Conclusions. The results suggest that the avoidance of CPB has no beneficial effect on the number of sternal wound complications in patients receiving bilateral internal thoracic artery grafting. However, further prospective, randomized studies on large patient groups are required to assess this finding.
Meharwal ZS, Mishra YK, Kohli V, et al. 2003. Multivessel off-pump coronary artery bypass: analysis of 4,953 cases. Heart Surg Forum 6(3): 153-9.nPeterson MD, Borger MA, Rao V, et al. 2003. Skletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes. J Thorac Cardiovasc Surg 126:1314-9.nEdgerton JR, Herbert MA, Jones KJ, et al. 2004. On-pump beating heart surgery offers an alternative for unstable patients undergoing coronary artery bypass grafting. Heart Surg Forum 7(1):8-15.nHe GW, Ryan WH, Acuff TE, et al. 1994. Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting. J Thorac Cardiovasc Surg 107:196-202.nCody C, Buggy DJ, Marsh B, et al. 2004. Subcutaneous tissue oxygenation after coronary revascularization with and without cardiopulmonary bypass. Anaesthesia 59:237-42.nBlanchard A, Hurni M, Ruchat P, et al. 1995. Incidence of deep and superficial sternal infection after open heart surgery: a ten years retrospective study from 1981 to 1991. Eur J Cardiothorac Surg 9:153-7.nLancey RA, Soller BR, Vander Salm TJ. 2000. Off-pump versus on pump coronary artery surgery: a case-matched comparison of clinical outcomes and costs. Heart Surg Forum 3(4):277-81.nHornick P, Taylor KM. 2000. Immune and inflammatory responses after cardiopulmonary bypass. In: Gravlee GP, Davis RF, Kurusz M, Utley JR, eds. Cardiopulmonary bypass principles and practice. 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 342-66.nPuskas JD, Williams WH, Duke PG, et al. 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: A prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797-808.nLorberboym M, Medalion B, Bder O, et al. 2002. 99m Tc-MDP bone SPECT for the evaluation of sternal ischemia following internal mammary artery dissection. Nucl Med Commun 23:47-52.nSabik JF, Gillinov AM, Blackstone EH, et al. 2002. Does off-pump reduce morbidity and mortality? J Thorac Cardiovasc Surg 124:698-707.nAscione R, Caputo M, Angelini GD. 2003. Off-pump coronary artery surgery bypass grafting: Not a flash in the pan. Ann Thorac Surg 75:306-13.nBerson AJ, Smith JM, Woods SE, et al. 2004. Off-pump versus on-pump coronary artery bypass surgery: does the pump influence outcome? J Am Coll Surg 199:102-8.nBorger MA, Rao V, Weisel RD, Ivanov J, et al. 1998. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 65:1050-6.nOttino G, De Paulis R, Pansini S, et al. 1987. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 44:173-9.nAlexiewicz JM, Kumar D, Smogorzewski M, et al. 1997. Elevated cytoso-lic calcium and impaired proliferation of B lymphocytes in type II diabetes mellitus. Am J Kidney Dis 30:98-104.nAscione R, Williams S, Lloyd CT, et al. 2001. Reduced postoperative blood loss and transfusion requirements after beating-heart coronary operations: a prospective randomized study. J Thorac Cardiovasc Surg 121:689-96.nButterworth JF, Prielipp RC. 2000. Endocrine, metabolic, and electrolyte responses. In: Gravlee GP, Davis RF, Kurusz M, Utley JR, eds. Cardiopulmonary bypass principles and practice. 2nd edition. Philadelphia, PA: Lippin-cott Williams & Wilkins; 342-66.nHoran TC, Gaynes RP, Martone WJ, et al. 1992. CDC definitions of nasocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infec Control Hosp Epidemiol 13(10):606-8.nPuskas JD, Thourani VH, Marshall JJ, et al. 2001. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off- pump coronary bypass patients. Ann Thorac Surg 71:1477-83.nDeuse T, Detter C, Samuel V, et al. 2003. Early and midterm results after coronary artery bypass grafting with and without cardiopulmonary bypass: which patient population benefits the most? Heart Surg Forum 6(2):77-83.nCohen AJ, Lockman J, Lorberboym M, et al. 1999. Assessment of sternal vascularity with single photon emission computed tomography after harvesting of the internal thoracic artery. J Thorac Cardiovasc Surg 118: 496-502.nGrossi EA, Esposito R, Haris LJ, et al. 1991. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 102:342-6.nLytle BW, Blackstone EH, Loop FD, et al. 1999. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 117:855-72.nLytle BW. 2001. Skletonized internal thoracic artery grafts and wound complications. J Thorac Cardiovasc Surg 121:625-7.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).