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Canadian Journal of Cardiology

A SINGLE-CENTRE CANADIAN EXPERIENCE USING RIGID PLATEFIXATION TO PREVENT STERNAL COMPLICATIONS AFTER OPEN-HEART SURGERY

      Background

      Sternal wound complications (SWC) occur in 0.4-5% of patients after cardiac surgery, and pose a serious risk to affected patients. In particular, deep sternal wound complications (osteomyelitis and mediastinitis) are associated with a mortality rate between 14-47%. Since July 2010, Royal Columbian Hospital has employed a strategy of using rigid plate fixation to primarily close the sterna of high-risk patients after open-heart surgery. We sought to determine the rate of SWCs in this group of patients, and describe their rates of peri-operative blood transfusions, hospital length-of-stay, and 30-day mortality.

      Methods

      We reviewed the experience of a single surgeon (TL) employing rigid plate fixation (with Biomet’s Sternalock system) at Royal Columbian Hospital from July 2010-March 2014. Patients were defined as high-risk on the basis of ≥ 2 of the following factors: diabetes mellitus, COPD, BMI ≥ 30kg/m2, renal failure, chronic steroid use, immunosuppression, osteoporosis, redo sternotomy, off-midline sternotomy, bilateral internal mammary artery harvest, cardiopulmonary bypass (CPB) time > 2h and transverse sternal fractures. Included patients: patients with ≥ 2 risk factors that received primary rigid plate fixation. Excluded patients: patients that received rigid plate fixation for a secondary indication (e.g. sternal revisions), received an alternative rigid closure device, or patients in another surgeon’s practice.

      Results

      Our analysis of 77 patients revealed a cohort with numerous risk-factors (RF): 24.7% had 2 RFs, 24.7% had 3 RFs, and the remaining patients had ≥4 RFs. 49.4% of patients had a history of diabetes mellitus, 72.7% had a BMI ≥ 30kg/m2, and 36.4% had CPB times > 2h. Only 3 (3.9%) patients developed a SWC, 1 of which was superficial and treatable with antibiotics alone. The other 2 (2.6%) patients developed a deep SWC requiring antibiotics and sternal revision. 76.5% of patients received ≤ 4 units of red blood cells peri-operatively, while 23.5% required more than 4 units. The mean hospital length-of-stay in this high-risk cohort was 12.6 days. 30-day mortality was 0%.

      Conclusions

      In a preliminary analysis of high-risk patients receiving primary rigid plate fixation, our data suggest that this pre-emptive strategy may reduce the incidence of SWCs. Furthermore, compared with historical controls, our study’s rigid plate fixation device is not associated with an increase in the rate of peri-operative blood transfusion. At CCC 2015, we will report the results of comparing our rigid plate fixation cohort with a propensity matched cohort generated using British Columbia’s central cardiac registry (Cardiac Services BC).