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Value of Perioperative Chest X-Ray for the Prediction of Sternal Wound Complications After Cardiac Surgery in High-Risk Patients: a “Work in Progress” Analysis

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Value of Perioperative Chest X-Ray for the Prediction of Sternal Wound Complications After Cardiac Surgery in High-Risk Patients: a “Work in Progress” Analysis Journal of Clinical Medicine Article Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A “Work in Progress” Analysis Andrea Ardigò 1,†, Alessandra Francica 1,† , Gian Franco Veraldi 2, Ilaria Tropea 1, Filippo Tonelli 1, Cecilia Rossetti 1, Francesco Onorati 1,* and Giuseppe Faggian 1 1 Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; [email protected] (A.A.); [email protected] (A.F.); [email protected] (I.T.); fi[email protected] (F.T.); [email protected] (C.R.); [email protected] (G.F.) 2 Vascular Surgery Unit, University Hospital in Verona, 37126 Verona, Italy; [email protected] * Correspondence: [email protected]; Tel.: +39-045-8123307 † Authors equally contributed to the study and should be considered both as first Author. Abstract: Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal Citation: Ardigò, A.; Francica, A.; height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of Veraldi, G.F.; Tropea, I.; Tonelli, F.; 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p < 0.001). Rossetti, C.; Onorati, F.; Faggian, G. Diabetes mellitus (O.R. 3.5; p < 0.001) and COPD (O.R. 21.3; p < 0.001) were independent predictors Value of Perioperative Chest X-ray for the Prediction of Sternal Wound for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p < 0.001) Complications after Cardiac Surgery with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p < 0.001). No other in High-Risk Patients: A “Work in radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion. Progress” Analysis. J. Clin. Med. 2021, PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound 10, 207. https://doi.org/10.3390/ complications, allowing for early preventative measures. jcm10020207 Keywords: sternal dehiscence; surgical site infection; cardiac surgery; sternal synthesis Received: 1 December 2020 Accepted: 6 January 2021 Published: 8 January 2021 1. Introduction Publisher’s Note: MDPI stays neu- tral with regard to jurisdictional clai- Sternal dehiscence (SD) is a rare but potentially ill and painful complication that can ms in published maps and institutio- occur after cardiac surgery, whose incidence is estimated to be between 0.2% to 3% [1]. nal affiliations. Despite its low incidence, SD has a relevant effect on healthcare outcomes. In-hospital mortality has been reported between 10% and 14.2% [2–5] and the mean length-of-stay up to 33 days [4,5]. One- and five-year survival has been estimated at 72.4% ± 4.4% and 55.8% ± 5.6%, respectively [4]. Excess treatment costs are also reported [4,5]. To date, Copyright: © 2021 by the authors. Li- several comorbidities have been identified as clear independent predictors of SD [6], and censee MDPI, Basel, Switzerland. different surgical techniques for sternal closure have been suggested across the decades This article is an open access article to prevent it [7]. In addition, some postoperative radiological stigmas (e.g., sternal gap distributed under the terms and con- >3 mm or sternal wire migration/fracture on chest X-ray or substernal fluid and air in ditions of the Creative Commons At- computed tomography) were demonstrated to confirm the occurrence of postoperative tribution (CC BY) license (https:// SD [8,9]. However, little attention to date has been paid to the existence of perioperative creativecommons.org/licenses/by/ radiological data that can predict the risk of postoperative SD. 4.0/). J. Clin. Med. 2021, 10, 207. https://doi.org/10.3390/jcm10020207 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 207 2 of 12 The chest X-ray has been a routine preoperative and postoperative examination after cardiac surgery since the dawn of this surgical specialty. The occurrence of SD has been early recognized as a risky complication, and different radiological examinations have been suggested to anticipate the clinical manifestation of SD [8,9]. Despite that, little attention has been paid to the potential predictive role of a routine chest X-ray. As an example, osteoporosis is considered a risk factor [6,10], and a biomechanical test with lateral sternal traction is reputed as the gold-standard to assess the tightness of different techniques of sternal closure [6,11]. Nevertheless, only one study has analyzed preoperative sternal thickness in terms of postoperative SD, with conflicting evidence [10]. Apart from sternal thickness, chronic obstructive pulmonary disease (COPD) and several functional respiratory parameters have been suggested as important risk factors for SD, but their radiological correlates have not been investigated [12–16]. According to the data mentioned above and to analyze the potential predictive role of chest X-ray on postoperative SD, we decided to collect data related to preoperative sternal thickness and perioperative height of different intercostal spaces (as indirect sign of hyperinflation and/or advanced COPD [15,16]) and correlate them with the postoperative development of SD. 2. Materials and Methods 2.1. Patients The retrospective study included consecutive patients considered at high risk for wound complications, who underwent surgery with sternotomy access from January 2018 to September 2020. Preoperative and postoperative characteristics were collected and used as criteria to identify high-risk patients for wound complications. Each patient met at least three high-risk factors for wound complications and surgical site infection according to published literature data [1–5]. 2.2. Institutional Protocol All patients underwent shaving the day before surgery and had a shower with chlorhexidine (CITROclorex 2% MD; Ecolab S.r.l, Vimercate, MB, Italy) on the morning of the planned operation, according to the preoperative preparation policy of the Division of Cardiac Surgery Verona. The institutional protocol provides antibiotic prophylaxis with cefazolin (Cefazolina Teva; Teva Pharmaceutical Industries, Milano, MI, Italy) 2 g 15–45 min before skin incision (3 g if weight >120 kg), repeated every 3 h during the operation and every 8 h until 24 h postoperation. In the case of methicillin-resistant Staphylococcus aureus colonization, vancomycin 1 g (Zengac; Fisiopharma S.r.l, Palomonte, SA, Italy) is indicated. The department protocol suggests the use of osteosynthesis with single interrupted steel wires (Monofilament stainless steel—Covidien llc, Mansfield, MA, USA) for patients considered at low risk for wound dehiscence, while the Robicsek technique is indicated in patients at high risk for wound complication. Therefore, all patients underwent primary sternal closure with the Robicsek technique [11] at the end of the index procedure, according to institutional guidelines. All patients underwent preoperative chest X-ray (posteroanterior (PA) and left lateral (LL) projections) the morning before planned cardiac surgery, as well as postoperative chest X-ray at ICU arrival and on postoperative day (POD) one (PA projection). All patients had already been extubated on POD one. 2.3. Study Design For the purpose of the study, besides preoperative and perioperative baseline charac- teristics, several measurements were retrospectively computed from preoperative chest X-ray (PA and LL projections) and the 1st POD X-ray (AP projection). More specifically (1) maximal sternal height at manubrium (proximal sternal height, PSH), at mid-body (medium sternal height, MSH), and at the level of body–xiphoid process junction (distal sternal height, DSH) measured from preoperative X-ray in LL projection (Figure1A); (2) the J. Clin. Med. 2021, 10, 207 3 of 12 2nd, 3rd and 4th left and right intercostal space height (pre-LISH and pre-RISH), measured at the level of the emiclavear line from preoperative X-ray in PA projection (Figure1B); (3) the 2nd, 3rd and 4th left and right intercostal space height (post-LISH and post-RISH), measured at the level of the emiclavear line from 1st POD X-ray (Figure1B). All of these measurements were collected as absolute values, as well as indexed measurements, after indexing for body surface area. Figure 1. Perioperative measurements at chest X-ray. (A) PSH: proximal sternal height; DSH: distal sternal height; MSH: midsternal height. (B) 2LISH: 2nd left intercostal space height; 3LISH: 3rd left intercostal space height; 4LISH: 4th left intercostal space height; 2RISH: 2nd right intercostal space height; 3RISH: 3rd right intercostal space height; 4RISH: 4th right intercostal
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