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Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery

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Abstract

Objectives

To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes.

Methods

In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively.

Results

Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3–6.3; p < 0.001–0.039). Addition of these CT parameters to CRP increased the model fit significantly (X2 = 17.9; p < 0.001; AUC, 0.83 vs. 0.73).

Conclusion

The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP.

Key Points

• Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis.

• Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.

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Abbreviations

CRP:

C-reactive protein

HU:

Hounsfield unit

ICC:

Intra-class correlation coefficient

IQR:

Inter-quartile range

Ln:

Lymph node

OR:

Odds ratio

ROI:

Region of interest

SD:

Standard deviation

VOI:

Volume of interest

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Acknowledgments

BF received unrelated funding from the German Research Foundation (DFG) project 290004377 (FO 993/1).

Funding

The authors state that this work has not received any funding.

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Author notes

  1. Borek Foldyna and Martin Mueller contributed equally to this work.

Authors and Affiliations

  1. Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Center, Struempellstrasse 39, 04289, Leipzig, Germany

    Borek Foldyna, Martin Mueller, Christian Luecke, Matthias Gutberlet & Lukas Lehmkuhl

  2. Cardiac MR PET CT Program, Massachusetts General Hospital – Harvard Medical School, Boston, MA, USA

    Borek Foldyna

  3. Department of Cardiac Surgery, University of Leipzig – Heart Center, Leipzig, Germany

    Christian D. Etz & Josephina Haunschild

  4. MVZ Laboratory Reising-Ackermann MD and Colleagues, Leipzig, Germany

    Ines Hoffmann

  5. Clinic for Radiology, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany

    Lukas Lehmkuhl

Authors
  1. Borek Foldyna
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Corresponding author

Correspondence to Borek Foldyna.

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The scientific guarantor of this publication is Prof. Dr. Matthias Gutberlet.

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The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise. No complex statistical methods were necessary for this paper.

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Foldyna, B., Mueller, M., Etz, C.D. et al. Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery. Eur Radiol 29, 2949–2957 (2019). https://doi.org/10.1007/s00330-018-5946-5

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  • DOI: https://doi.org/10.1007/s00330-018-5946-5

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