Eastern Cardiothoracic Surgical Society

Sternal Wound Complications in Patients Undergoing Orthotopic Heart Transplantation
Tyler J. Wallen, Andreas Habertheuer, Jean Paul Gottret, Matthew Kramer, Zara Abbas, Mary A. Siki, Reilly Hobbs, Charlie Vasquez, Suhail Kanchwala, David Lo, Michael Acker, Prashanth Vallabhajosyula, The University of Pennsylvania, Philadelphia, PA, USA


OBJECTIVE: The incidence and management of sternal wound complications in patients undergoing orthotopic heart transplantation (OHT) is not well studied. We report outcomes in OHT patients who developed sternal infections requiring reoperations in the perioperative period.

METHODS: From 2004 to 2013, 437patients underwent OHT at a single institution. In a retrospective review, patients who developed sternal infections post-OHT (Infection group, n=27) were compared to OHT patients without sternal complications (Control group, n=410).

RESULTS: Sternal infection rate was 6.2% (n=27). Demographics were similar. Infection group had higher rates of COPD 25% vs.13%, p=0.03, and previous cardiac surgery via sternotomy 28% vs.15%, p=0.03. Infection group had a greater incidence of ventilation >24hours, 44% vs. 31%, p=0.2, renal failure 56% vs. 24%, p=0.001, dialysis requirement 30% vs. 10%, p=0.006, permanent stroke 11% vs. 2%, p=0.02, perioperative MI 4% vs. 0.2%, p=0.09.The infection group had a longer ICU stay (524+410 vs. 187+355 hours, p=0.001) and hospitalization (59+28 vs .29+43 days, p=0.001). In-hospital/30-day mortality was 30% vs. 19%, p=0.2. 52% of the Infection Group were readmitted after discharge for sternal complications. Mean time to sternal reoperation was 44+50 days. Deep wound infection (41%) and sternal dehiscence (22%) were the most common presentations. Causative organisms were Enterobacter (22%), Klebsiella (15%), and Pseudomonas (15%). Surgical treatment included sternal debridement with pectoralis muscle flap (52%), primary closure (18%) and omental flap (11%). (Table 1).

CONCLUSIONS: Sternal wound infections impart a significant comorbid burden on OHT patients. Causative organisms are predominantly virulent gram negative bacteria. Therefore, a high index of suspicion must be maintained for early detection and treatment.

Table 1
Demographics and Preoperative Characteristics of Patients
with and without Postoperative Sternal Wound Infections

Variable Control Group (n = 410) Infection Group (n = 27) O.R. (95% C.I.)
No. (%) No. (%) p Value
Demographics
Age, years 54 9.4 53.4 12.35 0.75
Male 319 (77.8%) 22 (81.4%) 1.25 (0.46-3.4) 0.8
Cardiac comorbidity
Prior MI 162(40%) 12(37.5%) 1.23 (0.56-2.68) 0.7
Prior cardiac surgery 199(49.1%) 19(59.4%) 2.38 (1.07-5.88) 0.03
Prior Cardiac operations
VAD 68(17%) 9(28.1%) 1.76 (1.08-5.08) 0.03
CABG 86(21.2%) 10(31.2%) 2.21 (0.97-5.01) 0.06
Valve 52(12.8%) 6(18.8%) 1.96 (0.75-5.1) 0.15
Congenital defect 25(6.2%) 4(12.5%) 2.67 (0.85-8.35) 0.09
OHT 15(3.7%) 2(6.3%) 1.97 (0.45-9.72) 0.2
Root/ascending Aorta 3(0.7%) 0 0 1
Other* 14(3.4%) 1(3.1%) 0.8 (0.1-6.1) 1
Multiple 45(11.1%) 8(25%) 3.05 (1.4-8.25) 0.009
Noncardiac comorbidity
Peripheral arterial disease 37(9.1%) 4(12%) 1.67 (0.57-5.34) 0.3
Hypertension 360(87.8%) 25 (78.1%) 1.73 (0.39-7.55) 0.75
Diabetes 139(34.3%) 10(31.2%) 1.13 (0.51-2.57) 0.83
Smoking 140(34.6%) 13(40.6%) 1.72 (0.81-3.91) 0.15
Chronic obstructive pulmonary disease 53(13.1) 8(25%) 2.83 (1.18-6.8) 0.03
Preoperative renal failure 64(15.8%) 2(6.2%) 0.44 (0.1-1.87) 0.4
Preoperative renal dialysis 17(4.2%) 1(3.1%) 0.89 (0.1-6.95) 1
Prior stroke 39(9.6%) 2(6.2%) 0.77 (0.17-3.33) 1
Preoperative laboratory values
Creatinin 1.49 1.1 1.58 0.94 0.67
Hematocrit, % 34.5 5.7 35 4.8 0.65
*Lv aneurysm repair, Subaortic membrane myomectomy, pericardiectomy, clot removal, traumatic ventricular perforation repair.