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Reducing Surgical Site Infection
in Cardiac Surgery
Scott Schubach, MD
Chairman, Dept. of Thoracic & Cardiovascular Surgery
Winthrop University Hospital
Associate Professor, Surgery
Stony Brook School of Medicine
Presentation sponsored by ConvaTec

Introduction
Curriculum Vitae
 Education:
– Medical degree from Baylor College of Medicine
– Trained in general surgery at Dartmouth Hitchcock
Medical Center
– Trained in cardiac surgery at University of Pittsburgh

 Physician at Winthrop University Hospital since
1991
 Chairman of Dept. of Thoracic & Cardiovascular
Surgery since 2001

Introduction
Winthrop University Hospital
 Teaching hospital
 Affiliate of SUNY Stony
Brook
 Located in Mineola, NY
 520 open heart procedures
done annually by group of 4
surgeons

1

Surgical Site Infections (SSI)
Defined by CDC
 At or near operative site
 Occurs in post-op period
 Reportable if it occurs within 30
days post-op
 Three major sources
 Patient
 Healthcare Team
 OR environment

 Most common pathogens for
sternal wound infections1
 Staph aureus
 Staph epidermis
1Singh,

K et al, Overview and Management of Sternal Wound Infection, Seminars in Plastic Surgery, Volume 25, Number 1 2011

SSIs: Scope of the Problem
Surgical wound infections
 MOST common infection
in surgical patients
 Common nosocomial
infection
 Associated with substantial
morbidity and mortality1
– 60% more likely ICU admit
– 2x increase in mortality
during perioperative period

 post-op LOS1
 treatment costs1
1Banbury,

MK, Experience in prevention of sternal wound infections in nasal carriers of Staphylococcus aureus, Surgery, 2003

Nov

SSIs: Scope of the Problem
Cardiac Surgery
 Annual US procedural
volume:
– >600,000 cardiac procedures1
– 395,000 CABG procedures2

 3.5% infection rate postCABG procedures3
 Cost to treat mediastinitis
estimated to be $40,000 $50,0003
1Elgharably

H, et al. First Evidence of Sternal Wound Biofilm Following Cardiac Surgery, PLoS One, 2013 Aug 1;8(8),

2http://www.cdc.gov/nchs/fastats/insurg.htm, 3http://www.infectioncontroltoday.com/articles/2008/03/cabg-infections-are-

costly-and-dangerous-staffs-m.aspx

2

Sternal Wound Infections (SWI)
Risk Factors










Obesity
Renal insufficiency
Diabetes
COPD
Peripheral Vascular Disease
Existing pre-op infection
Steroid use
Malnutrition

Sternal Wound Infections
 Incidence of Sternal Wound Infection (SWI): 1-8%1
 SWI mortality rates reaching 40%1
 Treatment requires:1
– Prolonged antibiotic courses
– Repeated surgical interventions
– Longer hospital stay
 Can occur in any procedure requiring median
sternotomy
1

Elgharably H, et al. First Evidence of Sternal Wound Biofilm Following Cardiac Surgery, PLoS One, 2013 Aug 1;8(8)

Deep Sternal Wound Infections
 Increased hospital LOS > 2 full weeks compared
to any other post-op complication1
 Associated with other complications such as:1
– Prolonged ventilation
– Bleeding
– Renal failure
– Atrial fibrillation
– Increased rates of stroke
– Need for inotropic or mechanical cardiac
support
1Atkins,

Z, Wolfe, W, Sternal Wound Complications following Cardiac Surgery, www.intechopen.com

3

Reimbursement Challenges
 No CMS reimbursement for treatment of:
 SSI, mediastinitis, following Coronary
Artery Bypass Graft (CABG)
 SSI following Cardiac Implantable
Electronic Device (CIED)

http://www.cms.gov/HospitalAcqCond

State Reporting of SSI’s
Government Oversight and Physician Data
Tracking


Twenty one (21)states require hospitals to report
surgical site infection, 14 states so far have posted
the information publicly



Report and data available to public- CA, OR, WA,
CO, IL, MO, PA, OH, SC, NJ, NY, MA, VT And
NH

http://www.ama-assn.org/amednews/2012/04/02/prsb0402.htm

Winthrop Story





Increased Sternal Wound Infection rate
Infection rate is state and patient reportable
Hospitals do not get paid for Sternal Wound
Infection readmissions

Task force formed to reduce
incidence of SWI

4

Evaluated Current Practices






Operating room team’s sterile technique
Hand washing technique
Room ventilation
Instrument sterilization
Operating room traffic

Baseline SWI Prevention
Strategy


Adherence to core pre-operative antibiotic
protocols
– Administer antibiotics within 1 hour of
incision (2 hours for Vancomycin)

Approach to SWI Prevention
Address all potential sources of infection:
 Pre-operative Preparation
 Operating Room Environment
 Operating Room Team
 Post-operative Care of Patient and Wounds
 Patient Co-morbidities

5

Operation Room Environment


Limit traffic in and out of OR

Operating Room Team
1.

2.
3.

Stopped using Avagard gel and returned to
practice of scrubbing hands
Change gloves more frequently
Educated entire team on sterile field

Patient
1.

2.

3.

4.

Use chlorhexidine to cleanse the
skin
Apply occlusive dressing,
AQUACEL® Ag Surgical, in
operating room
Dressing left on for 5 days,
removed prior to discharge
Emphasize at discharge patients
can wash over incision with soap
and water

6

Considerations When Choosing
Surgical Dressing
1.

Permeable:
– Moist wound environment promotes healing
– Excessive moisture predisposed wounds to maceration and
blister formation

2.

Barrier:
– Prevent microbial ingress into wound
– Waterproof to allow showering

3.

Occlusive:
– Creates hypoxic environment
– Accelerates angiogenesis
National Institute for Health and Clinical Excellence.
Surgical Site Infection Guideline.

Gauze Dressings
Disadvantages


Non-Occlusive



Require Frequent Changes

– Non-optimal wound environment
– Exposure of wound
– Adhesive can cause skin injury


Not waterproof

Occlusive Dressings





Improved re-epithelialization
Increase in collagen synthesis by
2-6x compared to wounds open
to the air
Lower rate of wound infection
(Hutchinson study 1990)
– With occlusive dressing 2.6%
– With non-occlusive dressing 7.1%
Patel C, Surgical Wound Infections. Current Treatment in Infectious Diseases. 2000;2:147-153. Michie D. Influence of
Occlusive and Impregnated Dressings on Incisional Healing: Ann Plastic Surg. 1994. Hulten L. Dressings for Surgical
Wounds. Am J Surg. 1994. .Xi et al Wound Repair, 2000. Hutchinson, JJ, McGuckin, M, Occlusive dressings: A
microbiologic and clinical review, American Journal of Infection Control, Aug 1990

7

AQUACEL® Ag Surgical Dressing
Advantages
Barrier to pathogen transmission1
Microbicidal effects of silver ion2
Dressing may be left in place up to
7 days





– Less potential hospital exposure of
wound
– Less potential for pain associated
with dressing changes

Patient satisfaction



– Immediate showering
1 Nelson

Laboratories Report, Viral Penetration ASTM Method F1671, Procedure Number :ST0062 Rev07, Protocol Detail Sheet No.
200902139 Rev 1, Laboratory no. 483744, 7th August 2009
2 Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber dressing. Wound
Repair Regen. 2004;12(3):288-294.

Advanced Dressings
Hydrofiber® Technology





Basic component is cellulose
Carboxymethylation* process alters the absorption capacity
Hydrofiber® technology allows for fluid to be absorbed directly into
the fibers
A bond is formed with the absorbed fluid to hold it within the fiber
Cellulose fragment

*Carboxymethylation: addition of sodium carboxymethyl
1Waring

MJ, Parsons D. Physico-chemical characterisation of carboxymethylated spun cellulose fibres. Biomaterials. 2001;22:903-912.

AQUACEL® Ag
Broad-spectrum Antimicrobial Activity
Aerobic Bacteria

Antibiotic-resistant Bacteria

Staphylococcus aureus (NCTC 8532)

MRSA (NCTC 10442)

Staphylococcus aureus (clinical isolate)

MRSA (NCTC 12232)

Pseudomonas aeruginosa (clinical isolate, x2 strains)

MRSA (clinical isolate, x8 strains)

Enterobacter cloacae (clinical isolate)

VRE (NCTC 12201)

Streptococcus pyogenes (clinical isolate)

VRE (clinical isolate, x2 strains)

Klebsiella pnuemoniae (clinical isolate, x3 strains)

Serratia marcescens (clinical isolate)

Enterococcus faecalis (clinical isolate)

Pseudomonas aeruginosa (NTC 8506)

Escherichia coli (NCIMB 8545)
Escherichia coli (NCIMB 10544)
Acinetobacter baumannii (NCIMB 9214

Anerobic Bacteria

Yeasts

Bacteroides fragilis (clinical isolate)
Peptostreptococcus anaerobius (clinical isolate)

Candida albicans (NCPF 3179)
Candida albicans (NCPF 3265)

Clostridium ramosum (clinical isolate)
Clostridium clostridioforme (clinical isolate)
Clostridium cadaveris (clinical isolate)
Clostridium perfringens (clinical isolate)
Tissierella praeacute (clinical isolate)

Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber® dressing.
Would Repair Regen. 2004;12:288-294.

8

Hydrofiber® Ag Dressing
Bacterial Sequestration & Bactericidal Activity

T = 2-3 mins

T = 20 mins

Green = Alive
Red = Dead
T = Time in minutes

T = 40 mins

T = 60 mins

Confocal microscopy of Pseudomonas
aeruginosa on hydrated Hydrofiber® Ag
dressing fiber

Newman GR, Walker M, Hobot J, Bowler P. Biomaterials. 2006;27(7):1129-1139.

Dressing Change
Technique

Stretching of hydrocolloid portion (like stretching
“taffy”) allows gentle adhesive release from skin.
Skin traction is avoided

AQUACEL® Ag Surgical Dressing
CLINICAL RESULTS

9

Rothman Institute Study Results



Retrospective study- Journal of
Arthroplasty, 2014
1,778 patients undergoing
primary THA/TKA
– 875 standard gauze dressing
– 903 AQUACEL® Ag Surgical
dressing





76% reduction in incidence of
surgical site infection in
AQUACEL® Ag Surgical group
Multivariate analysis
– no other independent variables such
as patient co-morbidities, age, or
BMI impacted the reduction in
infection

Cai J, Karam JA, Parvizi J, Smith EB, Sharkey PF. The Aquacel® Ag Hydrofiber Wound Dressing with Ionic Silver Reduces the Rate
of Acute Periprosthetic Joint Infection Following Total Joint Arthroplasty., Poster presented at 22nd annual AAHKS meeting, Nov 2-4,
2012.

OrthoCarolina Clinical Trial Results
 Prospective Randomized Study –
American Journal of
Orthopedics, 2015

 AQUACEL® Ag Surgical vs.
Control

 300 pts
 Midterm analysis of 150
TKA (AAOS 2013)

 Significant reduction in wound
complications (p=0.009)

 Significantly less # dressing
changes (p<0.001)

 Improved patient satisfaction,
perception of hygiene
Springer, BD, Beaver, W, Griffin, W, Mason, JB, Dennos, A, Odum, S. The Role of Surgical Dressings in Total Knee Arthroplasty: A
Randomized Clinical Trial, Poster presented at 2013 AAOS annual meeting; March 19-23, 2013.

Winthrop AQUACEL® Ag
Surgical Study



Began using AQUACEL® Ag Surgical in May 2011
Conducted a study that involved*:
– Retrospective look at 503 patients with sternal incisions
covered with sterile 4x4 gauze pads and tape
– 208 patients with AQUACEL® Ag Surgical dressing



Patients included in the study were any patients
with a sternotomy incision

*Data

not yet submitted for publication

10

Study Results
Dressing Type

# of Deep SWI

%

Gauze and Tape

17
0

3.4%

AQUACEL® Ag
Surgical



of Deep SWI

0%

To date, approximately 500 patients have had the
AQUACEL® Ag Surgical dressing applied to their
sternal wound with only 1 deep sternal wound infection.

Thank You

Appendix

11

AQUACEL® Ag SURGICAL
Dressing
Skin-friendly hydrocolloid
technology flexes with the
skin during body movement1,3

Patented Hydrofiber® Technology
absorbs and locks in fluid,
including harmful bacteria.*2
Unique construction enhances
extensibility and flexibility

Polyurethane film provides
waterproof viral and bacterial
barrier *3
*As demonstrated in vitro

1Nelson

Laboratories Report, Viral Penetration ASTM Method F1671, Procedure Number :ST0062 Rev07, Protocol Detail Sheet No.
200902139, Rev 1, Laboratory no. 483744, 7th August 2009, 2Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron
microscopic examination of bacterial immobilisation in a carboxymethylcellulose (Aquacel) and alginate dressings. Biomaterials. 2003;
24:883-890.8. 3WHRI 3264 Laboratory Test Comparison of AQUACEL® Surgical Dressing ‘New Design’and the

Jubilee Method of Dressing Surgical Wounds . 7th Oct 2009

Dressing With Hydrofiber® Technology *
Locks in fluid*1
 Sequesters bacteria2,3
Traps harmful enzymes*4,5


®

Hydrofiber dressing

Alginate dressing

Gauze dressing

Sequestration test: a simple experiment using fluids of different colors to demonstrate the ability of dressings to lock in fluid
1Waring
2Walker

MJ, Parsons D. Biomaterials. 2001;22:903-912;
M, Hobot JA, Newman GR, Bowler PG. Biomaterials. 2003;24(5):883-890;
GR, Walker M, Hobot J, Bowler P. Biomaterials. 2006;27(7):1129-1139;
MJ, Hermans MHE, Richters CD, Dutrieux RP. J Wound Care. 2002;11(2):113-117;
M, Bowler PG, Cochrane CA. Ostomy Wound Manage. 2007;53(9):18-25.

3Newman

4Hoekstra
5Walker

*as demonstrated in vitro

Hydrofiber® Technology w/ Ionic Silver
AQUACEL® Ag Dressing





Reduction in bioburden to
reduce risk of infection is key
to optimal wound healing 1
Ionic silver (Ag) has broad
spectrum antimicrobial activity2
Hydrofiber® Ag dressing more
effective at killing bacteria in
vitro on simulated wounds with
uneven contours than a
nanocrystalline silvercontaining dressing 4

1Bowler

PG, Cochrane CA. Ostomy Wound Manage. 2003:49(8)(suppl):S2-S5;
J, Denyer SP. London: MEP Ltd, 2006:7-10.;
PG, Jones SA, Walker M, Parsons D. J Burn Care Rehabil. 2004;25:192-196;
S, Bowler PG, Walker M. Wounds. 2005;17(9):263-270.

2Maillard
3Bowler
4Jones

12

AQUACEL® Ag
Broad-spectrum Antimicrobial Activity
Aerobic Bacteria

Antibiotic-resistant Bacteria

Staphylococcus aureus (NCTC 8532)

MRSA (NCTC 10442)

Staphylococcus aureus (clinical isolate)

MRSA (NCTC 12232)

Pseudomonas aeruginosa (clinical isolate, x2 strains)

MRSA (clinical isolate, x8 strains)

Enterobacter cloacae (clinical isolate)

VRE (NCTC 12201)

Streptococcus pyogenes (clinical isolate)

VRE (clinical isolate, x2 strains)

Klebsiella pnuemoniae (clinical isolate, x3 strains)

Serratia marcescens (clinical isolate)

Enterococcus faecalis (clinical isolate)

Pseudomonas aeruginosa (NTC 8506)

Escherichia coli (NCIMB 8545)
Escherichia coli (NCIMB 10544)
Acinetobacter baumannii (NCIMB 9214

Anerobic Bacteria

Yeasts

Bacteroides fragilis (clinical isolate)
Peptostreptococcus anaerobius (clinical isolate)

Candida albicans (NCPF 3179)
Candida albicans (NCPF 3265)

Clostridium ramosum (clinical isolate)
Clostridium clostridioforme (clinical isolate)
Clostridium cadaveris (clinical isolate)
Clostridium perfringens (clinical isolate)
Tissierella praeacute (clinical isolate)

Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber® dressing. Would
Repair Regen. 2004;12:288-294.

Hydrofiber® Ag Dressing
Bacterial Sequestration & Bactericidal Activity

T = 2-3 mins

T = 20 mins

Green = Alive
Red = Dead
T = Time in minutes
T = 40 mins

T = 60 mins

Confocal microscopy of Pseudomonas
aeruginosa on hydrated Hydrofiber® Ag
dressing fiber

Newman GR, Walker M, Hobot J, Bowler P. Biomaterials. 2006;27(7):1129-1139.

13

5/2/2016

Incidence & Burden of Infections
Following Cardiac Surgery
Gorav Ailawadi, MD
Chief, Adult Cardiac Surgery
University of Virginia
May 2, 2016

Disclosures
•
•
•
•
•
•

Convatec
Abbott Vascular
St. Jude
Edwards
Mitralign
Atricure

Outline
• Overview of Major Infections Following
Cardiac Surgery
– Incidence
– Cost

• DSWI
• Pneumonia

1

5/2/2016

Hospital Acquired Infections
• 1.7 million individuals acquire HAI
• Leads to 100,000 deaths annually
• Results in additional $6.5 billion additional
health care expenditures

Perencevich EN, Pittet D. JAMA 2009; 301: 1285-7.

CTSN
• Supported by U01 HL088942

Cardiothoracic Surgical Trials Network
(CTSN)
• Funding Agencies:
• National Heart, Lung, and Blood Institute
• National Institute of Neurological Disorders and

Stroke
• Canadian Institutes for Health Research

2

5/2/2016

Investigators
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Data Coordinating Center: InCHOIR
Montefiore – Einstein
Emory University
Duke University
Hôpital Laval
University of Virginia Health System
Montreal Heart Institute
University of Pennsylvania
Columbia University Medical Center
Cleveland Clinic Foundation
University of Maryland
Brigham and Women's Hospital
Sacré-Cœur de Montréal
Ohio State University Medical
Center

•
•
•
•
•
•
•
•
•
•
•
•
•

East Carolina Heart Institute
Wellstar / Kennestone
Baylor Research Institute
University of Southern California
St. Michael’s Hospital
Toronto General Hospital
Mission Hospital
NIH Heart Center at Suburban
Hospital
Inova Heart & Vascular Institute
University of Alberta Hospital
Centre Hospitalier de l'Université de
Montréal
Sunnybrook Health Sciences Centre
Aarhus University

Methods
• 5,158 patients prospectively enrolled at 10 core

CTSN sites
• Infections identified and adjudicated up to 65

days after index surgery
• 4.6% (237 patients) experienced major infection
• SSI (sternum or secondary site), mediastinitis,
infectious pericarditis, endocarditis, cardiac device
infection, pneumonia, C Diff colitis

Frequency, Type and Timing of Infection

3

5/2/2016

Organism Type

Organism Type

Survival Impact of Major Infection

Gelijns AC, et al. J Am Coll Cardiol. 64(4):372-81, 2014.

4

5/2/2016

Sites of Infection
• Site of infection

N, %

Incidence

•
•
•
•
•
•

9 (30%)
8 (26.7%)
5 (16.7%)
4 (13.3%)
1 (3.3%)
1 (3.3%)

5.23%
4.65%
2.90%
2.32%
0.58%
0.58%

30 (100%)

17.42%

Bacteremia
Sternotomy site infection
Infection of vascular catheters
Pneumonia
Mediastinitis
Urinary tract infection

• Total

Lola, et. Al Journal of Cardiothoracic Surgery2011 6:151

Cost of Infection

5

5/2/2016

Average Cost Per Day With Infection

Incremental Costs By Type

Center Variability in Infection

6

5/2/2016

Circ Cardiovasc Qual Outcomes. 2014 Jul; 7(4): 567–573

Survival Impact of Infection

Circ Cardiovasc Qual Outcomes. 2014 Jul; 7(4): 567–573

DSWI

7

5/2/2016

DSWI Incidence and Impact
• Incidence ranges: 0.5% -6.8%
• In hospital Mortality: 7-35%
• 1 year survivors of DSWI: 15% survival
disadvantage
• 10 yr survival after CABG:
– Without DSWI: 70%
– With DSWI: 39%!

Cotogni P, et al. World J Crit Care Med. 4(4), 2015.

Survival Impact of DSWI

Bilal H, et al. Interact Cardiovasc Thorac Surg. 2013 17(3):479-484.

Timing of DSWI

8

5/2/2016

Pneumonia

CTSN: Pneumonia
•
•
•
•

2.4% (123 of 5,158 patients)
40% of all major infections
67% diagnosed during index hospitalization
86% diagnosed within 30 days
– 14% developed pneumonia after 1st month

Time to Pneumonia

9

5/2/2016

Impact of Pneumonia on Mortality
Variable

HR (95% CI)

P Value

Pneumonia

8.89 (5.02, 15.75)

<0.001

Age (year)

1.03 (1.01, 1.05)

<0.001

Male

0.60 (0.39, 0.91)

0.02

Diabetes* (yes/no)

1.57 (1.03, 2.41)

0.04

Heart Failure (yes/no)

1.86 (1.24, 2.80)

0.003

Creatinine, mg/dL

1.17 (1.06, 1.30)

0.002

Hemoglobin, g/dL

0.85 (0.75, 0.95)

0.005

Conclusions
•
•
•
•

Increasing patient comorbidities
Surgical infections still prevalent
Significant financial burden of infections
Significant mortality effect from infections

Conclusions
•
•
•
•

Increasing patient comorbidities
Surgical infections still prevalent
Significant financial burden of infections
Significant mortality effect from infections

• No consensus on Best Management!

10

5/2/2016

Thank You
• Questions?
• gorav@virginia.edu

11

5/2/2016

Risk Factors of Infections After
Cardiac Surgery
Justin Sambol MD FACS
Chief, Division of Cardiothoracic Surgery
Rutgers-New Jersey Medical School

Disclosures
 Consultant for ConVatec
 No other disclosures

Infections Following Cardiac Surgery

 Infection following cardiac surgery associated with
significant cost
 Increases hospital LOS
 Increases Morbidity
 Increases need for further surgery
 Increases mortality

1

5/2/2016

Types of Infections After Cardiac
Surgery
 Pneumonia
 Surgical Site Infections
 Superficial Sternal Wound Infections
 Deep Sternal Wound Infections
 Saphenectomy Site

 Septicemia

Why do Infections Occur?
 Preoperative Factors
 Intraoperative Events
 Postoperative Course

Preoperative Risk Factors








Age >70
Obesity with BMI >30 kg/m2
Immunosuppression
COPD
Diabetes (NIDDM as well as IDDM)
Renal Insufficiency
Critical preoperative status (infections,
sepsis, cardiogenic shock)

2

5/2/2016

Intraoperative Risk Factors
 Prolonged operative time
 Prolonged bypass time
 Use of Bilateral Internal
Mammary Artery
 Intraoperative use of blood
products

Postoperative Risk Factors





Prolonged mechanical ventilation
Vasopressor support
Need for transfusions
Reoperation for bleeding (data is variable)

From: Management Practices and Major Infections After Cardiac Surgery

J Am Coll Cardiol. 2014;64(4):372-381. doi:10.1016/j.jacc.2014.04.052

Table Title:
Baseline and Procedure Characteristics Associated With Infection

Date of download: 4/12/2016

Copyright © The American College of Cardiology. All rights reserved.

3

5/2/2016

Mitigation of Risk Factors









Optimization of blood glucose (HbA1C < 8.0%)
Reduce Obesity (BMI <30 kg/m2)
Cessation of Cigarette Smoking
Optimization of COPD
Avoid operative time > 7 hours
CPB time <180 min
Optimize postoperative cardiac output
Minimize bleeding and postoperative transfusion
Sajja LR, International Journal of Surgery 16 (2015) 171-178

Bilateral Internal Mammary Artery

 The use of Bilateral Internal
Mammary Artery (BIMA)
requires special
consideration
 Emerging data that BIMA
improves survival following
CABG
 Increased risk of Deep
Sternal Wound Infection???

David P. Taggart et al. Eur Heart J 2010;31:2470-2481
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2010. For permissions please email: journals.permissions@oxfordjournals.org

4

5/2/2016

Survival to 1 year.

David P. Taggart et al. Eur Heart J 2010;31:2470-2481
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2010. For permissions please email: journals.permissions@oxfordjournals.org

Table 3
Adverse event data by randomized group
SIMA (n = 1552) BIMA (n = 1542) Relative risk (95% CI)
Sternal wound reconstruction
No history of diabetes
Insulin-dependent diabetes
Non-insulin-dependent diabetes
MI event at 30 days
CVA event at 30 days
Revascularization at 30 days

9 (0.6%)
4
2
3
23 (1.5%)
19 (1.2%)
6 (0.4%)

MI event at 1 year
CVA event at 1 year
1.43)
Revascularization at 1 year

31 (2.0%)

29 (1.9%)
15
5
9
22 (1.4%)
15 (1.0%)
11 (0.7%)

3.24 (1.54–6.83)

0.96 (0.54–1.72)
0.79 (0.40–1.56)
1.85 (0.68–4.98)

30 (2.0%)
0.97 (0.59–1.60)
28 (1.8%)
23 (1.5%)
0.83 (0.48–

20 (1.3%) 27 (1.8%) 1.36 (0.77–2.41)

Conclusion
 Infections following cardiac surgery increase cost,
morbidity and mortality
 Risks of Infection are multifactorial
 Mitigation of these risks, when possible, can
significantly reduce the sequeli of these infection
 The benefits of the use of BIMA should be carefully
weighed against the added risk of infection

5



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