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J Thorac Cardiovasc Surg 1997;113:809-810
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Deep sternal wound infection after sternotomy

Hospital Epidemiology Unit
Bichat-Claude Bernard Hospital
Paris, France

Reply to the Editor:

The comments by Sousa Uva, Fischer, and Bical regarding the high frequency of deep sternal wound infections (DSWIs) after bilateral internal thoracic artery (ITA) grafting in our study deserve several answers.

Surveillance methods and definition of sternal infection in our study may partly explain the high ratio of DSWI. As indicated in the article, the prospective collection of DSWIs and prolonged surveillance after hospital discharge usually lead to a more sensitive and accurate detection of events in such risk factor studies. Specifically, risk of DSWI after bilateral ITA grafting was 1.5% to 3.8% in five retrospective studies ^1–5 and was 6.9% in one prospective study. ⁶

You raise the question of diagnosis of DSWI in the absence of sternal wound débridement. Indeed, the definition proposed by the Centers for Disease Control and Prevention relies on anatomic and clinical criteria. Ten of 42 sternal wound infections were limited to superficial sternal bone and were considered DSWIs. These patients did not undergo a reoperation, instead receiving local treatments.

Criteria for bilateral ITA grafting in the 10 centers were not known. However, 16 of the 126 (16%) patients who underwent bilateral ITA grafting were diabetic; 53 (42%) had moderate obesity (25 < body mass index 30) and 22 (17%) had morbid obesity (body mass index > 30); and 14 (11%) were older than 70 years. Applying the criteria currently in use in the Saint Joseph Hospital, 36 patients would have been excluded from bilateral ITA grafting and five of 11 DSWIs would have been avoided. Further studies, as recently exemplified by He and associates, ² are warranted to better define the population that would benefit from bilateral ITA grafting, together with low risks of DSWI. We fully agree that better perioperative techniques, especially operating room policies, would reduce the occurrence of DSWI in these high-risk patients.

References

1. Hazelrigg SR, Wellons HA, Schneider JA, Kolm P. Wound complications after medial sternotomy. J Thorac Cardiovasc Surg 1989;98:1096-9.[Abstract]
   
2. He GW, Ryan WH, Acuff TE, et al. Risk factors for operative mortality and sternal wound infection in bilateral internal mammary artery grafting. J Thorac Cardiovasc Surg 1994;107:196-202.[Abstract/Free Full Text]
   
3. Galbut DL, Traad EA, Dorman MJ, et al. Seventeen years experience with bilateral internal mammary grafts. Ann Thorac Surg 1990;49:195-201.[Abstract]
   
4. Grossi EA, Esposito R, Harris LJ, et al. Sternal wound infection and use of internal mammary artery grafts. J Thorac Surg 1991;102:342-7.[Abstract]
   
5. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary bypass grafting: early and late mortality, morbidity and cost of care. Ann Thorac Surg 1990;49:179-87.[Abstract]
   
6. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG. Risks of bilateral internal mammary artery grafting. Ann Thorac Surg 1990;49:210-9.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lucet, J.-C. Search for Related Content PubMed Articles by Lucet, J.-C.