Marc Albert, Adrian Ursulescu, Ulrich FW Franke Department of Cardiovascular Surgery Robert-Bosch-Hospital, Stuttgart, Germany
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1 The total arterial myocardial revascularization using bilateral IMA and the role of post-operative sternal stabilization to reduce wound infections in a large cohort study. Marc Albert, Adrian Ursulescu, Ulrich FW Franke Department of Cardiovascular Surgery Robert-Bosch-Hospital, Stuttgart, Germany Präsentation Robert-Bosch-Krankenhaus 1
2 The Guidelines for Coronary Artery Bypass Grafting Präsentation Robert-Bosch-Krankenhaus 2
3 General Advantages of the Total Arterial Myocardial Off-Pump Revascularization Real No Aortic Touch technique possible Total arterial off-pump revascularization is associated with: Lower mortality, stroke rate, perioperative myocardial infarction Shorter ventilation time Shorter ICU-LOS, Hospital-LOS BIMA use: Best graft patency Standard operation in our department (94% in 2015) Präsentation Robert-Bosch-Krankenhaus 3
4 Downside of Total Arterial (Bilateral IMA) Off-Pump Revascularization Technically challenging Needs Sternotomy Risk of Deep Sternal Wound Infection Especially in patients with Obesity or Diabetes Präsentation Robert-Bosch-Krankenhaus 4
5 Standard Sternal Osteosynthesis in Patients after median Sternotomy 8 Sternal wires in single loop technique Gentamycin collagen implant 5 x 20 cm (Sulmycin / Collatamp, EUSA Pharma, UK) 3 layer skin closure: suture of fascia, subcutaneous tissue, intracutanious suture Präsentation Robert-Bosch-Krankenhaus 5
6 POSTHORAX Support Vest Every patient after median sternotomy Fitting the vest before surgery Patients starting to wear vest after removal of thoracic drainage Patients are instructed to wear the vest for 8 weeks (Rehabilitation hospitals informed) Präsentation Robert-Bosch-Krankenhaus 6
7 Why Support Vest Sternum instability major risk factor for wound complications Instability caused by Mobilization, Exercise Delirium Respiration Support vest stabilizes sternum and prevents friction between the two sternum half Lowers incidence of wound complication? Präsentation Robert-Bosch-Krankenhaus 7
8 Studies Reduction mediastinitis from 2.27% to 1.04%: -54% Präsentation Robert-Bosch-Krankenhaus 8
9 Studies Reduction mediastinitis from 2.39% to 0.88%: -63% Präsentation Robert-Bosch-Krankenhaus 9
10 Studies Reduction mediastinitis from 2.39% to 0.88%: -72% Präsentation Robert-Bosch-Krankenhaus 10
11 The POSTHORAX Vest Präsentation Robert-Bosch-Krankenhaus 11
12 Study design Retrospective Study All patients received total-arterial revascularization using BIMA Vest introduced in April 2015 for all sternotomy patients Comparison of: 515 patients July 2014 March 2015: no vest 471 patients April December 2015: POSTHORAX vest Wound infections were treated using a vacuum therapy (VacuSeal, KCI) Präsentation Robert-Bosch-Krankenhaus 12
13 Aim of this Study Compare the incidence of wound complications after bilateral IMA grafting according to the use of the POSTHORAX vest Präsentation Robert-Bosch-Krankenhaus 13
14 Demographic Data Posthorax vest (n=471) No vest (n=515) p-value Age 68.5 ± ± 10.0 p=0.803 Male 394 (83.5%) 435 (85%) p=0.672 BMI [kg/m²] 37.4 ± ± 13.9 p=0.311 Euroscore 6.4 ± ± 3.6 p=0.917 Insulin depended Diabetes 41 (8.7%) 45 (8.7%) p=0.446 Dialysis 3 (0.6%) 4 (0.8%) p=0.910 PVD 39 (8,3%) 62 (12%) p=0.049 Präsentation Robert-Bosch-Krankenhaus 14
15 Intra- & postoperative Data Posthorax vest (n=471) No vest (n=515) p-value Resuscitation post-op 7 (1.5%) 9 (1.7%) p=0.614 Re-Thoracotomy 10 (2.1%) 12 (2.3%) p=0.911 Dialysis (acute + chronic) 6 (1.3%) 7 (1.4%) p=0.750 Skin-skin time [min] 192 ± ± 35 p=0.404 No. anastomosis 3.2 ± ± 0.9 p=0.872 Myocardial infarction 6 (1.3%) 6 (1.2%) p=0.651 Mortality 6 (1.3%) 10 (1.9%) p=0.471 Präsentation Robert-Bosch-Krankenhaus 15
![Wound complications Posthorax vest (n=471) No vest (n=515) p-value Wound complication [No] 2 (0.4%) 9 (1.7%) 0.044 No of wound revisions per patient 5.0 ± 2.8 5.1 ± 2.4 0.](/docs-images/72/67642081/images/16-1.jpg "955 Onset of Complication after operation [weeks] Hospital length of stay w/ wound complication [d] 3.0 ± 0.0 3.8 ± 2.4 0.357 17.0 ± 3.4 29.6 ± 9.7 0.")
16 Wound complications Posthorax vest (n=471) No vest (n=515) p-value Wound complication [No] 2 (0.4%) 9 (1.7%) No of wound revisions per patient 5.0 ± ± Onset of Complication after operation [weeks] Hospital length of stay w/ wound complication [d] 3.0 ± ± ± ± Präsentation Robert-Bosch-Krankenhaus 16
17 Conclusion Significantly lower incidence for wound complications in patients after BIMA grafting with the POSTHORAX vest Vest is accepted by the patients as a tool for lowering incidence of wound complication good compliance (if every patient wears a vest) Rehabilitation hospitals have to be instructed about the deployment, benefits and duration of the postoperative use of a thorax stabilization vest Präsentation Robert-Bosch-Krankenhaus 17
18 Thank you for your attention Präsentation Robert-Bosch-Krankenhaus 18
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