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1

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

2

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 post-

CABG 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

3

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

1Elgharably 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

4

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

Task force formed to reduce

incidence of SWI

Increased Sternal Wound Infection rate

Infection rate is state and patient reportable

Hospitals do not get paid for Sternal Wound

Infection readmissions

5

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

6

Operation Room Environment

Limit traffic in and out of OR

Operating Room Team

1. Stopped using Avagard gel and returned to

practice of scrubbing hands

2. Change gloves more frequently

3. Educated entire team on sterile field

Patient

1. Use chlorhexidine to cleanse the

skin

2. Apply occlusive dressing,

AQUACEL®Ag Surgical, in

operating room

3. Dressing left on for 5 days,

removed prior to discharge

4. Emphasize at discharge patients

can wash over incision with soap

and water

7

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

–Non-optimal wound environment

Require Frequent Changes

–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

8

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

2Jones 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.

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

1Waring MJ, Parsons D. Physico-chemical characterisation of carboxymethylated spun cellulose fibres. Biomaterials. 2001;22:903-912.

*Carboxymethylation: addition of sodium carboxymethyl

Cellulose fragment

Advanced Dressings

Hydrofiber®Technology

AQUACEL® Ag

Broad-spectrum Antimicrobial Activity

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.

Aerobic Bacteria

Staphylococcus aureus (NCTC 8532)

Staphylococcus aureus (clinical isolate)

Pseudomonas aeruginosa (clinical isolate, x2 strains)

Enterobacter cloacae (clinical isolate)

Streptococcus pyogenes (clinical isolate)

Klebsiella pnuemoniae (clinical isolate, x3 strains)

Enterococcus faecalis (clinical isolate)

Escherichia coli (NCIMB 8545)

Escherichia coli (NCIMB 10544)

Acinetobacter baumannii (NCIMB 9214

Anerobic Bacteria

Bacteroides fragilis (clinical isolate)

Peptostreptococcus anaerobius (clinical isolate)

Clostridium ramosum (clinical isolate)

Clostridium clostridioforme (clinical isolate)

Clostridium cadaveris (clinical isolate)

Clostridium perfringens (clinical isolate)

Tissierella praeacute (clinical isolate)

Antibiotic-resistant Bacteria

MRSA (NCTC 10442)

MRSA (NCTC 12232)

MRSA (clinical isolate, x8 strains)

VRE (NCTC 12201)

VRE (clinical isolate, x2 strains)

Serratia marcescens (clinical isolate)

Pseudomonas aeruginosa (NTC 8506)

Yeasts

Candida albicans (NCPF 3179)

Candida albicans (NCPF 3265)

9

Hydrofiber®Ag Dressing

Bacterial Sequestration & Bactericidal Activity

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

T = 20 mins

T = 60 mins

T = 2-3 mins

T = 40 mins

Green = Alive

Red = Dead

T = Time in minutes

Confocal microscopy of Pseudomonas

aeruginosa on hydrated Hydrofiber®Ag

dressing fiber

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

10

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

Rothman Institute Study Results

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

11

Study Results

To date, approximately 500 patients have had the

AQUACEL®Ag Surgical dressing applied to their

sternal wound with only 1 deep sternal wound infection.

Dressing

Type

# of Deep

SWI

%

of Deep SWI

Gauze and Tape

17

3.4%

AQUACEL

® Ag

Surgical

0

0%

Thank You

Appendix

12

AQUACEL®Ag SURGICAL

Dressing

Polyurethane film provides

waterproof viral and bacterial

barrier *3

Patented Hydrofiber®Technology

absorbs and locks in fluid,

including harmful bacteria.*2

Unique construction enhances

extensibility and flexibility

Skin-friendly hydrocolloid

technology flexes with the

skin during body movement1,3

*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

Locks in fluid*1

Sequesters bacteria2,3

Traps harmful enzymes*4,5

Hydrofiber®dressing Alginate dressing Gauze dressing

1Waring MJ, Parsons D. Biomaterials. 2001;22:903-912;

2Walker M, Hobot JA, Newman GR, Bowler PG. Biomaterials. 2003;24(5):883-890;

3Newman GR, Walker M, Hobot J, Bowler P. Biomaterials. 2006;27(7):1129-1139;

4Hoekstra MJ, Hermans MHE, Richters CD, Dutrieux RP. J Wound Care. 2002;11(2):113-117;

5Walker M, Bowler PG, Cochrane CA. Ostomy Wound Manage. 2007;53(9):18-25.

Dressing With Hydrofiber®Technology *

*as demonstrated in vitro

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

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 silver-

containing dressing 4

1Bowler PG, Cochrane CA. Ostomy Wound Manage. 2003:49(8)(suppl):S2-S5;

2Maillard J, Denyer SP. London: MEP Ltd, 2006:7-10.;

3Bowler PG, Jones SA, Walker M, Parsons D. J Burn Care Rehabil. 2004;25:192-196;

4Jones S, Bowler PG, Walker M. Wounds. 2005;17(9):263-270.

13

AQUACEL® Ag

Broad-spectrum Antimicrobial Activity

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.

Aerobic Bacteria

Staphylococcus aureus (NCTC 8532)

Staphylococcus aureus (clinical isolate)

Pseudomonas aeruginosa (clinical isolate, x2 strains)

Enterobacter cloacae (clinical isolate)

Streptococcus pyogenes (clinical isolate)

Klebsiella pnuemoniae (clinical isolate, x3 strains)

Enterococcus faecalis (clinical isolate)

Escherichia coli (NCIMB 8545)

Escherichia coli (NCIMB 10544)

Acinetobacter baumannii (NCIMB 9214

Anerobic Bacteria

Bacteroides fragilis (clinical isolate)

Peptostreptococcus anaerobius (clinical isolate)

Clostridium ramosum (clinical isolate)

Clostridium clostridioforme (clinical isolate)

Clostridium cadaveris (clinical isolate)

Clostridium perfringens (clinical isolate)

Tissierella praeacute (clinical isolate)

Antibiotic-resistant Bacteria

MRSA (NCTC 10442)

MRSA (NCTC 12232)

MRSA (clinical isolate, x8 strains)

VRE (NCTC 12201)

VRE (clinical isolate, x2 strains)

Serratia marcescens (clinical isolate)

Pseudomonas aeruginosa (NTC 8506)

Yeasts

Candida albicans (NCPF 3179)

Candida albicans (NCPF 3265)

Hydrofiber®Ag Dressing

Bacterial Sequestration & Bactericidal Activity

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

T = 20 mins

T = 60 mins

T = 2-3 mins

T = 40 mins

Green = Alive

Red = Dead

T = Time in minutes

Confocal microscopy of Pseudomonas

aeruginosa on hydrated Hydrofiber®Ag

dressing fiber

5/2/2016

1

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

5/2/2016

2

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

5/2/2016

3

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

5/2/2016

4

Organism Type

Organism Type

Survival Impact of Major Infection

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

5/2/2016

5

•Site of infection N, % Incidence

•Bacteremia 9 (30%) 5.23%

•Sternotomy site infection 8 (26.7%) 4.65%

•Infection of vascular catheters 5 (16.7%) 2.90%

•Pneumonia 4 (13.3%)2.32%

•Mediastinitis 1 (3.3%) 0.58%

•Urinary tract infection 1 (3.3%) 0.58%

•Total 30 (100%) 17.42%

Sites of Infection

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

Cost of Infection

5/2/2016

6

Average Cost Per Day With Infection

Incremental Costs By Type

Center Variability in Infection

5/2/2016

7

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

5/2/2016

8

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

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9

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

5/2/2016

10

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!

5/2/2016

11

Thank You

•Questions?

•gorav@virginia.edu

5/2/2016

1

Risk Factors of Infections After

Cardiac Surgery

Justin Sambol MD FACS

Chief, Division of Cardiothoracic Surgery

Rutgers-New Jersey Medical School

Consultant for ConVatec

No other disclosures

Disclosures

Infection following cardiac surgery associated with

significant cost

Increases hospital LOS

Increases Morbidity

Increases need for further surgery

Increases mortality

Infections Following Cardiac Surgery

5/2/2016

2

Pneumonia

Surgical Site Infections

Superficial Sternal Wound Infections

Deep Sternal Wound Infections

Saphenectomy Site

Septicemia

Types of Infections After Cardiac

Surgery

Preoperative Factors

Intraoperative Events

Postoperative Course

Why do Infections Occur?

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)

Preoperative Risk Factors

5/2/2016

3

Prolonged operative time

Prolonged bypass time

Use of Bilateral Internal

Mammary Artery

Intraoperative use of blood

products

Intraoperative Risk Factors

Prolonged mechanical ventilation

Vasopressor support

Need for transfusions

Reoperation for bleeding (data is variable)

Postoperative Risk Factors

Date of download: 4/12/2016 Copyright © The American College of Cardiology. All rights reserved.

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

Baseline and Procedure Characteristics Associated With Infection

Table Title:

5/2/2016

4

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

Mitigation of Risk Factors

Sajja LR, International Journal of Surgery 16 (2015) 171-178

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???

Bilateral Internal Mammary Artery

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

5/2/2016

5

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 9 (0.6%) 29 (1.9%) 3.24 (1.54–6.83)

No history of diabetes 4 15

Insulin-dependent diabetes 2 5

Non-insulin-dependent diabetes 3 9

MI event at 30 days 23 (1.5%) 22 (1.4%) 0.96 (0.54–1.72)

CVA event at 30 days 19 (1.2%) 15 (1.0%) 0.79 (0.40–1.56)

Revascularization at 30 days 6 (0.4%) 11 (0.7%) 1.85 (0.68–4.98)

MI event at 1 year 31 (2.0%) 30 (2.0%) 0.97 (0.59–1.60)

CVA event at 1 year 28 (1.8%) 23 (1.5%) 0.83 (0.48–

1.43)

Revascularization at 1 year 20 (1.3%) 27 (1.8%) 1.36 (0.77–2.41)

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

Conclusion