Department of Cardiac Surgery, Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada.
Department of Cardiac Surgery, Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada.
Ann Thorac Surg. 2019 Sep;108(3):737-743. doi: 10.1016/j.athoracsur.2019.03.046. Epub 2019 Apr 15.
The optimal sternal closure technique in patients at elevated risk after cardiac surgery has not been elucidated.
Between January 2006 and July 2015, 15,048 consecutive adult patients underwent cardiac surgery via median sternotomy using cardiopulmonary bypass. Rigid sternal fixation using 3 separate techniques (peristernal polyether ether-ketone banding, titanium plating, and stainless steel multibraided cables with cannulated screws) was used in 1111 patients (group A), whereas conventional peristernal/transsternal wiring was used in 13,937 patients (group B). Predictors of deep sternal wound infection or dehiscence were evaluated, and propensity score analysis was used to create 2 matched groups; 1050 group A patients (94.5%) were matched to group B patients.
Mean time to presentation was 31 ± 70.3 days (median, 19) after surgery. There was a decreased incidence of deep sternal wound infection or dehiscence among propensity score-matched group A compared with group B patients (1.9% vs 2.7%, P = .13), although it was not statistically significant. On multivariate analysis, group A was associated with a 33% relative risk reduction of deep sternal wound infection or dehiscence (odds ratio, 0.67; 95% confidence interval, 0.48-0.94; P = .02); this was entirely due to a protective effect associated with polyether ether-ketone banding (odds ratio, 0.4; 95% confidence interval, 0.3-0.7; P = .0002). In the subgroup of bilateral internal mammary artery grafting patients (n = 886), there was a strong protective trend associated with preventative sternal fixation, although it was not statistically significant (odds ratio, 0.3; 95% confidence interval, 0.09-1.09; P = .06).
Primary sternal fixation in patients at risk of sternal complications is associated with decreased sternal infection and/or dehiscence. Primary fixation may expand the use of bilateral internal mammary artery grafting to patient populations at increased risk for sternal complications.
心脏手术后高危患者的最佳胸骨闭合技术尚未阐明。
2006 年 1 月至 2015 年 7 月，连续 15048 例成年患者通过体外循环经正中胸骨切开术进行心脏手术。1111 例患者（A 组）采用 3 种不同技术（胸骨旁聚醚醚酮带、钛板和带套管螺钉的不锈钢多编织缆线）进行硬性胸骨固定，而 13937 例患者（B 组）采用传统胸骨旁/胸骨内缝线。评估了深部胸骨伤口感染或裂开的预测因素，并使用倾向评分分析创建了 2 个匹配组；1050 例 A 组患者（94.5%）与 B 组患者匹配。
术后中位时间为 31 ± 70.3 天（中位数为 19）出现症状。与匹配的 B 组患者相比，A 组患者深部胸骨伤口感染或裂开的发生率降低（1.9%比 2.7%，P=.13），但无统计学意义。多变量分析显示，A 组患者深部胸骨伤口感染或裂开的相对风险降低 33%（优势比，0.67；95%置信区间，0.48-0.94；P=.02）；这完全归因于聚醚醚酮带的保护作用（优势比，0.4；95%置信区间，0.3-0.7；P=.0002）。在双侧内乳动脉移植患者亚组（n=886）中，尽管无统计学意义，但预防性胸骨固定与保护趋势有关（优势比，0.3；95%置信区间，0.09-1.09；P=.06）。
高危胸骨并发症患者的原发性胸骨固定与胸骨感染和/或裂开减少相关。原发性固定可能会扩大双侧内乳动脉移植的应用范围，使高风险胸骨并发症患者获益。
