ISSN : 1301-5680
e-ISSN : 2149-8156
Turkish Journal of Thoracic and Cardiovascular Surgery     
Kalp cerrahisinde ameliyat sonrası mediastinitle ilişkili risk etkenleri: Sistematik derleme ve meta analiz
Selen Öztürk1, İbrahim Öztürk2, Seher İlhan3
1Department of Cardiovascular Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
2Department of Anaesthesiology and Reanimation, Göztepe Training and Research Hospital, İstanbul, Turkey
3Department of Anaesthesiology and Reanimation, Medical Faculty of Uludağ University, Bursa, Turkey
DOI : 10.5606/tgkdc.dergisi.2015.10754


Background: In this review, we aimed to analyze the risk factors of mediastinitis after open cardiac surgery.

Methods: The literature screening was performed at Pubmed, Ovid, and Sciencedirect databases without date limitation. Studies investigating the co-existing diseases were included. The results of trials were evaluated with random or fixed effect model according to the heterogeneity.

Results: A total of 5009 articles were attained after database searching. Thirty five articles were included to the metaanalysis including 131.158 patients who met inclusion criteria. The most possible preoperative risk factors for mediastinitis were atrial fibrillation, pulmonary disease, diabetes mellitus, renal disease, peripheral vascular disease and systemic hypertension (p<0.05). Pulmonary hypertension, malignancy, hepatic and neurological diseases, heart failure and dyslipidemia were not found to be risk factors (p>0.05). Heterogeneity was not observed for four (renal, hepatic, neurological and peripheral vascular diseases) of 12 factors (I2<25%).

Conclusion: The results of our meta-analysis showed that preoperative co-existing diseases such as pulmonary hypertension, malignancy, heart failure, hepatic and neurological diseases, and dyslipidemia may not be risk factors for the development of mediastinitis following cardiac surgery.

Mediastinitis, also know as deep sternal wound infection (DSWI), is a rare, serious complication often seen after open cardiac surgery which may increase the length of intensive care unit (ICU) and/or hospital stays and also may cause a higher mortality rate. Researchers have reviewed the preoperative, intraoperative and postoperative variables for predicting postoperative mediastinitis development,[1-5] and coexisting diseases, such as diabetes mellitus (DM) and systemic hypertension (HT) along with pulmonary, renal, hepatic, and neurological diseases, were generally examined in those studies. However, we found controversy regarding the association between postoperative mediastinitis and those diseases. Therefore, in this study, we aimed to review and analyze the literature to determine which preoperative variables can be used to predict mediastinitis.


Search strategy
We performed the database search and analyzed the article in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).[6] Two authors searched the PubMed electronic database to determine whether or not coexisting diseases could predict the development of mediastinitis after cardiac surgery. The search concluded on January 5th, 2014, and there were no limitations related to this date.

The search was conducting using the following English keywords or a combination of these words: cardiac surgery, heart surgery, valve surgery, coronary artery bypass grafting (CABG), mediastinitis, and DSWI. The search was limited to English, with articles in other languages being excluded from the study. In addition, the study was limited to clinical trials, comparative studies, multicenter studies, observational studies, randomized controlled trials, controlled clinical trials, and evaluation studies.

Selection of studies
The studies, regardless of sample size, included both retrospective and prospective clinical studies. Inclusion criteria were that it was a clinical study that involved open cardiac surgery with off-pump or extracorporeal circulation and that the article was in English. Experimental studies, articles not in English, and those that focused on non-cardiac surgery were excluded from the study. Furthermore, articles that were associated with our review topic but did not contain information concerning the rate of mediastinitis according to preoperative coexisting diseases were also excluded as well as those that contained data with figures but no numerical values.

Data extraction
Two reviewers independently extracted data from the relevant studies, and any disagreements were resolved by consensus using a third reviewer. At first, we gathered the publication information (first author's name, publication year, patient population, and type of surgery), characteristics of the participants (sample size and type of study methods), and outcome information (mediastinitis rate, number of diseases, number of control cases, and definition of mediastinitis) and then recorded the number of patients with and without mediastinitis (controls).

Statistical analysis
Statistical analysis was carried out using the Comprehensive Meta-Analysis (CMA) Version 2.0 (Biostat, Englewood, New Jersey, USA), and the odds ratio (OR) and 95% confidence interval (CI) (lower-upper limit) was utilized for this analysis. The heterogeneity was evaluated using the statistics of I2, with it being accepted as significant if I2 >25%. In addition, the heterogeneity was classified as low (25% < I2 > 50%.), moderate (50% < I2 > 75%.), or high (I2 >75%) and was evaluated by analyzing subgroups and moderators. The meta-analysis was performed by using fixed or random effect models, with the latter being conducted in the presence of heterogeneity (I2 > 25%) and the former without heterogeneity (I2 <25%). The overall e ffect was analyzed via a Z score, and potential publication bias was evaluated using the Begg test.


A flow diagram of the database search is shown in Figure 1. We identified 5,009 records and filtered these down to 999 articles. After duplicates were removed, 374 records remained, and 255 of these were excluded after screening because they were deemed to be unrelated to our topic. Then the full text of 119 articles were assessed for their eligibility, and 83 were excluded because of the absence of detailed data regarding gender in each group. This left 36 articles that were included in the quantitative synthesis.[1-5,7-36] The demographic features of these studies are summarized in Table 1. The ratio of development of mediastinitis was 1.99% (2,619 cases out of 131,158). Results of analysis, heterogeneity and publication bias are shown in Table 2-14.

Figure 1: Flow diaphragm of database search.

Table 1: Studies included in the analysis

Table 1: (continued)

Table 2: Results of analysis

Table 3: Pulmonary hypertension and mediastinitis

Table 4: Malignancy and mediastinitis

Table 5: Hepatic disease and mediastinitis

Table 6: Dyslipidemia and mediastinitis

Table 7: Neurological disease and mediastinitis

Table 8: Atrial fibrillation and mediastinitis

Table 9: Peripheral vascular disease and mediasitinitis

Table 10: Heart failure and mediastinitis

Table 11: Renal disease and mediastinitis

Table 12: Systemic hypertension and mediastinitis

Table 13: Diabetes mellitus and mediastinitis

Table 14: Pulmonary disease and mediastinitis


Cardiac surgery is special because of both the individual properties of the patients and the operative procedures. Advanced age and coexisting diseases are common causes of morbidity, with invasive interventions [e.g., arterial cannulation, central venous catheterization, cardiopulmonary bypass (CPB), intra-aortic balloon pumps (IABPs), blood transfusions, and ICU stays being other possible sources of infection. In addition, invasive interventions may lead to the entry of bacterial pathogens.[37]

Kansy et al.[38] found that the ratio of major infections (septicemia, endocarditis, and mediastinitis) was 3.1% after cardiac surgery, and Chen et al.[39] also found a similar ratio for major infections (3.2%), with the risk factors being a high body mass index (BMI), previous CABG, emergency surgery, renal impairment, heart failure, peripheral and cerebrovascular diseases, and immunsuppression.

Many of the coexisting diseases, such as DM,[40] heart failure,[41] pulmonary disease,[23] and malignancy,[42] may decrease a patient’s resistance against infection while longer treatment durations of other conditions (AF and systemic HT) can increase the duration of ICU and hospital stays. Hence, the possibility of infection is also higher.

In our meta-analysis, some of the diseases occurred less frequently. Three studies featured pulmonary HT, two focused on malignancy, four had cases of hepatic disease, four included patients with dyslipidemia, three featured neurological disease, and three had cases of AF. The most studied diseases were DM (29 studies), renal disease (16 studies), systemic HT (15 studies), heart failure (12 studies), and peripheral vascular disease (10 studies). We did not observe heterogeneity for the studies that focused on peripheral vascular and renal disease (I2 < 25%). F urthermore, t he heterogeneity of the studies that featured DM and systemic HT was low (25%< I2 < 50%), but it was high for those that included patients with heart failure (I2 >75%).

The ratio of mediastinitis development was approximately 2%. However, future studies are needed because only nine of the 35 studies had a large sample size (>5,000) (23,499 in Baillot et al.,[9] 15,406 in Braxton et al.,[10] 11,848 in Robinson et al.,[28] 11,748 in Elenbaas et al.,[15] 10,713 in Eklund et al.,[14] 9,303 i n Gummert e t a l.,[19] 7,583 in Hallam et al.,[20] 5,798 in Filsoufi et al.,[16] and 5,649 in Floros et al.[5] However, none of these included the majority of the factors we wanted to assess in their analyses. When we excluded[5,9,10,14-16,19,20,28] those results from our analysis, the present results changed as opposite for pulmonary HT, hepatic and neurological disease, AF, and heart failure.

We used the definition of mediastinitis, type of surgery, and study design as moderators to analyze the reason for heterogeneity and found that the heterogeneity did not change based on the definition of mediastinitis or type of surgery. However, study design was a primary cause of heterogeneity.

In the literature, there were many studies that discussed the presence of mediastinitis after cardiac surgery. However, the main limitation of our metaanalysis was that we excluded studies because of their design and the absence of needed data. Another limitation was that we excluded the patients’ individual demographic characteristics, such as age and gender, along with the intraoperative variables (e.g., the presence or absence of CPB and aortic cross-clamp time) because we focused on coexisting diseases.


The results of our meta-analysis showed that preoperative coexisting diseases, such as pulmonary HT, malignancy, heart failure, hepatic and neurological diseases, and dyslipidemia, may not be risk factors for the development of mediastinitis after cardiac surgery. However, there is still a need for large, randomized, controlled studies to decrease the heterogeneity of analysis.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.


1) Bitkover CY, Gårdlund B. Mediastinitis after cardiovascular operations: a case-control study of risk factors. Ann Thorac Surg 1998;65:36-40.

2) Antunes PE, Bernardo JE, Eugénio L, de Oliveira JF, Antunes MJ. Mediastinitis after aorto-coronary bypass surgery. Eur J Cardiothorac Surg 1997;12:443-9.

3) Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after coronary artery bypass grafting risk factors and long-term survival. Ann Thorac Surg 2010;89:1502-9.

4) Parissis H, Al-Alao B, Soo A, Orr D, Young V. Risk analysis and outcome of mediastinal wound and deep mediastinal wound infections with specific emphasis to omental transposition. J Cardiothorac Surg 2011;6:111.

5) Floros P, Sawhney R, Vrtik M, Hinton-Bayre A, Weimers P, Senewiratne S, et al. Risk factors and management approach for deep sternal wound infection after cardiac surgery at a tertiary medical centre. Heart Lung Circ 2011;20:712-7.

6) Moher D, Liberati A, Tetzlaff J, Altman DG for PRISMA group. Preferred reporting items for systematic reviews and meta-analysis: the PRISMA statement. BMJ 2009;339:332-6.

7) Abboud CS, Wey SB, Baltar VT. Risk factors for mediastinitis after cardiac surgery. Ann Thorac Surg 2004;77:676-83.

8) Dodds Ashley ES, Carroll DN, Engemann JJ, Harris AD, Fowler VG Jr, Sexton DJ, et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2004;38:1555-60.

9) Baillot R, Cloutier D, Montalin L, Côté L, Lellouche F, Houde C, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies. Eur J Cardiothorac Surg 2010;37:880- 7.

10) Braxton JH, Marrin CA, McGrath PD, Ross CS, Morton JR, Norotsky M, et al. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 2000;70:2004-7.

11) Colombier S, Kessler U, Ferrari E, von Segesser LK, Berdajs DA. Influence of deep sternal wound infection on long-term survival after cardiac surgery. Med Sci Monit 2013;19:668-73.

12) Dial S, Nguyen D, Menzies D. Autotransfusion of shed mediastinal blood: a risk factor for mediastinitis after cardiac surgery? Results of a cluster investigation. Chest 2003;124:1847-51.

13) Diez C, Koch D, Kuss O, Silber RE, Friedrich I, Boergermann J. Risk factors for mediastinitis after cardiac surgery - a retrospective analysis of 1700 patients. J Cardiothorac Surg 2007;2:23.

14) 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;82:1784-9.

15) Elenbaas TW, Soliman Hamad MA, Schönberger JP, Martens EJ, van 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;89:704-9.

16) Filsoufi F, Castillo JG, Rahmanian PB, Broumand SR, Silvay G, Carpentier A, et al. Epidemiology of deep sternal wound infection in cardiac surgery. J Cardiothorac Vasc Anesth 2009;23:488-94.

17) Ghotaslou R, Yagoubi AR, Khalili AA, Mahmodian R. Ghotaslou R, Yagoubi AR, Khalili AA, Mahmodian R. Jpn J Infect Dis 2008;61:318-20.

18) Gualis J, Flórez S, Tamayo E, Alvarez FJ, Castrodeza J, Castaño M. Risk factors for mediastinitis and endocarditis after cardiac surgery. Asian Cardiovasc Thorac Ann 2009;17:612-6.

19) Gummert JF, Barten MJ, Hans C, Kluge M, Doll N, Walther T, et al. Mediastinitis and cardiac surgery--an updated risk factor analysis in 10,373 consecutive adult patients. Thorac Cardiovasc Surg 2002;50:87-91.

20) Hallam J, Skillington P, Law SS, Nordstrand I, Tatoulis J. A Review of deep sternal wound infection rates and prevention practices in cardiac surgery. Heart, Lung and Circulation 2011;20:250–284

21) Lin CH, Hsu RB, Chang SC, Lin FY, Chu SH. Poststernotomy mediastinitis due to methicillin-resistant Staphylococcus aureus endemic in a hospital. Clin Infect Dis 2003;37:679-84.

22) López Gude MJ, San Juan R, Aguado JM, Maroto L, López- Medrano F, Cortina Romero JM, et al. Case-control study of risk factors for mediastinitis after cardiovascular surgery. Infect Control Hosp Epidemiol 2006;27:1397-400.

23) Manganas H, Lacasse Y, Bourgeois S, Perron J, Dagenais F, Maltais F. Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease. Can Respir J 2007;14:19-24.

24) Muñoz P, Menasalvas A, Bernaldo de Quirós JC, Desco M, Vallejo JL, Bouza E. Postsurgical mediastinitis: a casecontrol study. Clin Infect Dis 1997;25:1060-4.

25) Newman LS, Szczukowski LC, Bain RP, Perlino CA. Suppurative mediastinitis after open heart surgery. A case control study of risk factors. Chest 1988;94:546-53.

26) Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, Movahedi N, et al. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis 2007;7:112.

27) Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-75.

28) Robinson PJ, Billah B, Leder K, Reid CM; ASCTS Database Committee. Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria. Interact Cardiovasc Thorac Surg 2007;6:167-71.

29) Rosmarakis ES, Prapas SN, Rellos K, Michalopoulos A, Samonis G, Falagas ME. Nosocomial infections after off-pump coronary artery bypass surgery: frequency, characteristics, and risk factors. Interact Cardiovasc Thorac Surg 2007;6:759-67.

30) Sá MP, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, et al. Risk factors for mediastinitis after coronary artery bypass grafting surgery. Rev Bras Cir Cardiovasc 2011;26:27-35.

31) Sá MP, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, et al. Skeletonized left internal thoracic artery is associated with lower rates of mediastinitis in diabetic patients. Rev Bras Cir Cardiovasc 2011;26:183-9.

32) Sakamoto H, Fukuda I, Oosaka M, Nakata H. Risk factors and treatment of deep sternal wound infection after cardiac operation. Ann Thorac Cardiovasc Surg 2003;9:226-32.

33) San Juan R, Chaves F, López Gude MJ, Díaz-Pedroche C, Otero J, Cortina Romero JM, et al. Staphylococcus aureus poststernotomy mediastinitis: description of two distinct acquisition pathways with different potential preventive approaches. J Thorac Cardiovasc Surg 2007;134:670-6.

34) 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;11:1146-53.

35) Tiveron MG, Fiorelli AI, Mota EM, Mejia OA, Brandão CM, Dallan LA, et al. Preoperative risk factors for mediastinitis after cardiac surgery: analysis of 2768 patients. Rev Bras Cir Cardiovasc 2012;27:203-10.

36) Wouters R, Wellens F, Vanermen H, De Geest R, Degrieck I, De Meerleer F. Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. Tex Heart Inst J 1994;21:183-8.

37) Kluge RM, Calia FM, McLaughlin JS, Hornick RB. Sources of contamination in open heart surgery. JAMA 1974;230:1415-8.

38) Kansy A, Jacobs JP, Pastuszko A, Mirkowicz-Małek M, Manowska M, Jezierska E, et al. Major infection after pediatric cardiac surgery: external validation of risk estimation model. Ann Thorac Surg 2012;94:2091-5.

39) Chen LF, Arduino JM, Sheng S, Muhlbaier LH, Kanafani ZA, Harris AD, et al. Epidemiology and outcome of major postoperative infections following cardiac surgery: risk factors and impact of pathogen type. Am J Infect Control 2012;40:963-8.

40) Spelman DW, Russo P, Harrington G, Davis BB, Rabinov M, Smith JA, et al. Risk factors for surgical wound infection and bacteraemia following coronary artery bypass surgery. Aust N Z J Surg 2000;70:47-51.

41) Maile MD, Engoren MC, Tremper KK, Jewell E, Kheterpal S. Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg 2014;119:522-32.

42) Kadija S, Stefanović A, Jeremić K, Tavcar J, Argirović R, Pantović S. Malignant disease as a risk factor for surgical site infection. Clin Exp Obstet Gynecol 2012;39:53-6.

Keywords : Kalp cerrahisi; mediastinit; risk etkeni
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