RBCCV Brazilian Journal of Cardiovascular Surgery Revista Brasileira de Cirurgia Cardiovascular

ISSN (on-line): 1678-9741
ISSN (Print): 0102-7638 Impact Factor: 0.963 Prof. Zerbini - 100 anos

Sorry! This article does not have a Portuguese version.

EMC - Make the Test

Volume 26 Number 2, April - June, 2011

ORIGINAL ARTICLE

DOI: http://dx.doi.org/10.1590/S0102-76382011000200007

Artéria torácica interna esquerda esqueletizada é associada a menores taxas de mediastinite em diabéticos

Skeletonized left internal thoracic artery is associated with lower rates of mediastinitis in diabetic patients

Michel Pompeu Barros de Oliveira Sá⁰; Evelyn Figueira Soares⁰; Cecília Andrade Santos⁰; Omar Jacobina Figueiredo⁰; Renato Oliveira Albuquerque Lima⁰; Rodrigo Renda Escobar⁰; Fábio Gonçalves de Rueda⁰; Paulo Ernando Ferraz⁰; Ricardo Carvalho Lima

^IMD, MSc ^IIMD ^IIIMD, MSc, PhD, ChM

Correspondence To:
Michel Pompeu Barros de Oliveira Sá
Av. Eng. Domingos Ferreira, 4172/405 - Boa Viagem
Recife, PE, Brasil - CEP 51021-040
E-mail: michel_pompeu@yahoo.com.br

RESUMO

INTRODUÇÃO: Mediastinite é uma complicação séria da esternotomia mediana e está associada a significativa morbidade e mortalidade. Diabetes é um temido fator de risco para mediastinite, visto com cautela pelos cirurgiões cardiovasculares.
OBJETIVO: Identificar fatores de risco para mediastinite em diabéticos submetidos à CRM com uso unilateral da ATI na Divisão de Cirurgia Cardiovascular do Pronto Socorro Cardiológico de Pernambuco - PROCAPE.
MÉTODOS: Estudo retrospectivo de 157 pacientes diabéticos operados entre maio de 2007 e abril de 2010. Nove variáveis pré-operatórias, cinco variáveis intraoperatórias e sete variáveis pós-operatórias possivelmente envolvidas no desenvolvimento de mediastinite foram avaliadas. Análises univariada e multivariada por regressão logística foram aplicadas.
RESULTADOS: A incidência de mediastinite foi de 7% (n=11), com taxa de letalidade de 36,1% (n=4). Variáveis associadas com maior risco de mediastinite foram: uso de ATI pediculada (OR 8,25, IC 95% 2,03-66,10, P=0,016), complicações renais (OR 5,10, IC 95% 1,03-25,62, P = 0,049) e reoperação (OR 7,45, IC 95% 1,24-42,17, P=0,023). Na análise multivariada por regressão logística, apenas uma variável permaneceu como fator independente de risco: uso ATI pediculada (OR 7,64, IC 95% 1,95-61,6, P = 0,048), em comparação à ATI esqueletizada.
CONCLUSÕES: Sugerimos que diabéticos devem ser considerados para estratégias de minimização do risco de infecção. Nos diabéticos que recebem ATI unilateral, o problema parece estar relacionado à forma como a ATI é dissecada. Diabéticos devem sempre ser considerados para utilização da ATI esqueletizada.

Keywords Mediastinite. Revascularização miocárdica. Diabetes mellitus. Artéria Torácica Interna.

ABSTRACT

BACKGROUND: Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. Diabetes is a feared risk factor for mediastinitis and viewed with caution by cardiovascular surgeons.
OBJECTIVE: To identify risk factors for mediastinitis in diabetics undergoing CABG surgery with use of unilateral ITA in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE.
METHODS: Retrospective study of 157 diabetics operated between May 2007 and April 2010. Nine preoperative variables, five intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. Univariate and multivariate logistic regression analyses were applied.
RESULTS: The incidence of mediastinitis was 7% (n=11), with a lethality rate of 36.1% (n=4). Variables associated with increased risk of mediastinitis were: use of pedicled ITA (OR 8.25, 95% CI 2.03 to 66.10, P=0.016), postoperative renal complications (OR 5.10, 95% CI 1.03 to 25.62, P=0.049) and re-operation (OR 7.45, 95% CI 1.24 to 42.17, P=0.023). In multivariate analysis using backward logistic regression, only one variable remained as independent risk factor: use of pedicled ITA (OR 7.64, 95% CI 1.95 to 61.6, P=0.048), in comparison to skeletonized ITA.
CONCLUSIONS: We suggest that diabetics should be considered for strategies to minimize risk of infection. In diabetics that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Diabetics should always be considered for use of skeletonized ITA.

Palavras-Chave Mediastinitis. Myocardial revascularization. Diabetes mellitus. Mammary arteries.

REFERENCES

1. Sá MPBO, Soares EF, Santos CA, Figueiredo OJ, Lima ROA, Escobar RR, et al. Fatores de risco para mediastinite após cirurgia de revascularização miocárdica. Rev Bras Cir Cardiovasc. 2011;26(1):27-35. [See article]

2. Magedanz EH, Bodanese LC, Guaragna JCVC, Albuquerque LC, Martins V, Minossi SD, et al. Elaboração de escore de risco para mediastinite pós-cirurgia de revascularização do miocárdio. Rev Bras Cir Cardiovasc. 2010;25(2):154-9. [MedLine] [See article]

3. Arruda MVF, Braile DM, Joaquim MR, Suzuki FA, Alves RH. O uso da vancomicina em pasta na hemostasia do esterno e profilaxia da mediastinite. Rev Bras Cir Cardiovasc. 2008;23(1):35-9. [MedLine] [See article]

4. Nina VJS, Assef MAS, Rodrigues RR, Mendes VGG, Lages JS, Amorim AMM, et al. Reconstrução da parede torácica com suporte metálico externo: técnica alternativa na mediastinite pós-esternotomia. Rev Bras Cir Cardiovasc. 2008;23(4):507-11. [MedLine] [See article]

5. Elenbaas TW, Soliman Hamad MA, Schönberger JP, Martens EJ, Zundert AA, van Straten AH. Preoperative atrial fibrillation and elevated C-reactive protein levels as predictors of mediastinitis after coronary artery bypass grafting. Ann Thorac Surg. 2010;89(3):704-9. [MedLine]

6. Eklund AM, Lyytikäinen O, Klemets P, Huotari K, Anttila VJ, Werkkala KA, et al. Mediastinitis after more than 10,000 cardiac surgical procedures. Ann Thorac Surg. 2006;82(5):1784-9. [MedLine]

7. Matros E, Aranki SF, Bayer LR, McGurk S, Neuwalder J, Orgill DP. Reduction in incidence of deep sternal wound infections: random or real? J Thorac Cardiovasc Surg. 2010;139(3):680-5. [MedLine]

8. Sá MP, Silva DO, Lima EN, Lima Rde C, Silva FP, Rueda FG, et al. Postoperative mediastinitis in cardiovascular surgery. Analysis of 1038 consecutive surgeries. Rev Bras Cir Cardiovasc. 2010;25(1):19-24. [MedLine] [See article]

9. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67(2):352-60.

10. Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63(2):356-61. [MedLine]

11. Toumpoulis IK, Anagnostopoulos CE, Balaram S, Swistel DG, Ashton RC Jr, DeRose JJ Jr. Does bilateral internal thoracic artery grafting increase long-term survival of diabetic patients? Ann Thorac Surg. 2006;81(2):599-606. [MedLine]

12. De Paulis R, de Notaris S, Scaffa R, Nardella S, Zeitani J, Del Giudice C, et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization. J Thorac Cardiovasc Surg. 2005;129(3):536-43. [MedLine]

13. Toumpoulis IK, Anagnostopoulos CE, Derose JJ Jr, Swistel DG. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest. 2005;127(2):464-71. [MedLine]

14. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-32. [MedLine]

15. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61(3):1030-6. [MedLine]

16. Ståhle E, Tammelin A, Bergström R, Hambreus A, Nyström SO, Hansson HE. Sternal wound complications: incidence, microbiology and risk factors. Eur J Cardiothorac Surg. 1997;11(6):1146-53. [MedLine]

17. The Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg. 1996;111(6):1200-7. [MedLine]

18. Friedman ND, Bull AL, Russo PL, Leder K, Reid C, Billah B, et al. An alternative scoring system to predict risk for surgical site infection complicating coronary artery bypass graft surgery. Infect Control Hosp Epidemiol. 2007;28(10):1162-8. [MedLine]

19. Saso S, James D, Vecht JA, Kidher E, Kokotsakis J, Malinovski V, et al. Effect of skeletonization of the internal thoracic artery for coronary revascularization on the incidence of sternal wound infection. Ann Thorac Surg. 2010;89(2):661-70. [MedLine]

20. Kai M, Hanyu M, Soga Y, Nomoto T, Nakano J, Matsuo T, et al. Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics. Ann Thorac Surg. 2007;84(1):32-6. [MedLine]

21. Milani R, Brofman PR, Guimarães M, Barboza L, Tchaik RM, Meister Filho H, et al. Double skeletonized internal thoracic artery vs. double conventional internal thoracic artery in diabetic patients submitted to OPCAB. Rev Bras Cir Cardiovasc. 2008;23(3):351-7. [MedLine]

22. Boodhwani M, Lam BK, Nathan HJ, Mesana TG, Ruel M, Zeng W, et al. Skeletonized internal thoracic artery harvest reduces pain and dysesthesia and improves sternal perfusion after coronary artery bypass surgery: a randomized, double-blind, within-patient comparison. Circulation. 2006;114(8);766-73. [MedLine]

23. Kamiya H, Akhyari P, Martens A, Karck M, Haverich A, Lichtenberg A. Sternal microcirculation after skeletonized versus pedicled harvesting of the internal thoracic artery: a randomized study. J Thorac Cardiovasc Surg. 2008;135(1):32-7. [MedLine]

24. Santos Filho EC, Moraes Neto FR, Silva RA, Moraes CR. Should the diabetics have the internal thoracic artery skeletonized? Assessment of sternal perfusion by scintillography. Rev Bras Cir Cardiovasc. 2009;24(2):157-64. [MedLine] [See article]

25. Abboud CS, Wey SB, Baltar VT. Risk factor for mediastinitis after cardiac surgery. Ann Thorac Surg. 2004;77(2):676-83. [MedLine]