Variables predicting adverse outcome in patients with deep sternal wound infection

Infectious Mediastinitis: A Retrospective Cohort Study

Background

This study aimed to characterize the demographics, microbiology, management and treatment outcomes of mediastinitis according to the origin of the infection.

Methods

This retrospective observational study enrolled patients who had mediastinitis diagnosed according to the criteria defined by the Centers for Disease Control and Prevention and were treated in Strasbourg University Hospital, France, between 1 January 2010 and 31 December 2020.

Results

We investigated 151 cases, including 63 cases of poststernotomy mediastinitis (PSM), 60 cases of mediastinitis due to esophageal perforation (MEP) and 17 cases of descending necrotizing mediastinitis (DNM). The mean patient age (standard deviation) was 63 (14.5) years, and 109 of 151 patients were male. Microbiological documentation varied according to the origin of the infection. When documented, PSM cases were mostly monomicrobial (36 of 53 cases [67.9%]) and involved staphylococci (36 of 53 [67.9%]), whereas MEP and DNM cases were mostly plurimicrobial (38 of 48 [79.2%] and 8 of 12 [66.7%], respectively) and involved digestive or oral flora microorganisms, respectively. The median duration of anti-infective treatment was 41 days (interquartile range, 21-56 days), and 122 of 151 patients (80.8%) benefited from early surgical management. The overall 1-year survival rate was estimated to be 64.8% (95% confidence interval, 56.6%-74.3%), but varied from 80.1% for DNM to 61.5% for MEP.

Conclusions

Mediastinitis represents a rare yet deadly infection. The present cohort study exhibited the different patterns observed according to the origin of the infection. Greater insight and knowledge on these differences may help guide the management of these complex infections, especially with respect to empirical anti-infective treatments.

Chronic thoracic pain after cardiac surgery: role of inflammation and biomechanical sternal stability

Introduction

The pathogenesis of chronic chest pain after cardiac surgery has not been determinate. If left untreated, postoperative sternal pain reduces the quality of life and patient satisfaction with cardiac surgery. The purpose of the study was to examine the effect of chest inflammation on postoperative pain, risk factors for chronic pain after cardiac surgery and to explore how chest reconstruction was associated with the intensity of pain.

Methods

The authors performed a study of acute and chronic thoracic pain after cardiac surgery in patients with and without sternal infection and compared different techniques for chest reconstruction. 42 high-risk patients for the development of mediastinitis were included. Patients with mediastinitis received chest reconstruction (group 1). Their demographics and risk factors were matched with no-infection patients with chest reconstruction (group 2) and subjects who underwent conventional sternal closure (group 3). Chronic pain was assessed by the numeric rating scale after surgery.

Results

The assessment of the incidence and intensity of chest pain at 3 months post-surgery demonstrated that 14 out of 42 patients across all groups still experienced chronic pain. Specifically, in group 1 with sternal infection five patients had mild pain, while one patient experienced mild pain in group 2, and eight patients in group 3. Also, follow-up results indicated that the highest pain score was in group 3. While baseline levels of cytokines were increased among patients with sternal infection, at discharge only the level of interleukin 6 remained high compared to no infection groups. Compared to conventional closure, after chest reconstruction, we found better healing scores at 3-month follow-up and a higher percentage of patients with the complete sternal union.

Conclusions

Overall, 14 out of 42 patients have chronic pain after cardiac surgery. The intensity of the pain in mediastinitis patients significantly decreased at 3 months follow-up after chest reconstruction. Thus, post-surgery mediastinitis is not a determining factor for development the chronic chest pain. There is no correlation between cytokines levels and pain score except interleukin 6 which remains elevated for a long time after treatment. Correlation between sternal healing score and chronic chest pain was demonstrated.

Factors associated with deep sternal wound infection after open-heart surgery in a Danish registry

Objective

To conduct a comprehensive multivariate analysis of variables associated with deep sternal wound infection, after open-heart surgery via median sternotomy.

Method

A retrospective cohort of all adult patients, who underwent open-heart surgery at Odense University Hospital between 01-01-2000 and 31-12-2020 was extracted from the West Danish Heart Registry. Data were analyzed using maximum likelihood logistic regression.

Results

A total of 15,424 patients underwent open-heart surgery and 244 developed a deep sternal wound infection, equivalent to 1,58 %. After data review 11,182 entries were included in the final analysis, of which 189 developed DSWI, equivalent to 1,69 %. Multivariate analysis found the following variables to be associated with the development of deep sternal wound infection (odds ratios and 95%confidens intervals in parentheses): Known arrhythmia (1.70; 1.16-2.44), Left Ventricular Ejection Fraction (1.66; 1.02-2.58), Body Mass Index 25-30 (1.66; 1.12-2.52), Body Mass Index 30-35 (2.35; 1.50-3.71), Body Mass Index 35-40 (3.61; 2.01-6.33), Body Mass Index 40+ (3.70; 1.03-10.20), Age 60-69 (1.64; 1.04-2.67), Age 70-79 (1.95; 1.23-3.19), Chronic Obstructive Pulmonary Disease (1.77; 1.21-2.54), Reoperation (1.63; 1.06-2.45), Blood transfusion in surgery (1.09; 1.01-1.17), Blood transfusion in intensive care unit (1.03; 1.01-1.06), Known peripheral atherosclerosis (1.82; 1.25-2.61), Current smoking (1.69; 1.20-2.35), Duration of intubation (1.33; 1.12-1.57).

Conclusion

Increased risk of deep sternal wound infection after open-heart surgery is a multifactorial problem, while some variables are unchangeable others are not. Focus should be on optimizing the condition of the patient prior to surgery e.g. weight loss and smoking. But also factors surrounding the patient e.g. preventing blood loss and minimizing intubation time.

Characteristics and outcomes of patients with postoperative Candida versus bacterial mediastinitis: a case-matched comparative study

OBJECTIVES

Postoperative mediastinitis, a feared complication after cardiac surgery, is associated with high mortality, especially of critically ill patients. Candida species infections are rare and severe, with poorly known outcomes. We conducted a case-control study to describe the characteristics, management and outcomes of patients with postoperative Candida mediastinitis.

METHODS

This French, monocentre, retrospective study included all patients with postoperative Candida mediastinitis (January 2003-February 2020) requiring intensive care unit admission. Candida mediastinitis patients (henceforth cases) were matched 1:1 with postoperative bacterial mediastinitis (henceforth control), based on 3 factors during mediastinitis management: age >40 years, cardiac transplantation and invasive circulatory device used. The primary end point was the probability of survival within 1 year after intensive care unit (ICU) admission.

RESULTS

Forty cases were matched to 40 controls. The global male/female ratio was 2.1, with mean age at admission 47.9 ± 13.8 years. Candida species were: 67.5% albicans, 17.5% glabrata, 15% parapsilosis, 5.0% tropicalis, 2.5% krusei and 2.5% lusitaniae. The median duration of mechanical ventilation was 23, 68.8% of patients received renal replacement therapy and 62.5% extracorporeal membrane oxygenation support. The probability of survival within the first year after ICU admission was 40 ± 5.5% and was significantly lower for cases than for controls (43 ± 8% vs 80 ± 6.3%, respectively; Log-rank test: P < 0.0001). The multivariable Cox proportional hazards model retained only renal replacement therapy [hazard ratio (HR) 3.7, 95% confidence interval (CI) 1.1-13.1; P = 0.04] and Candida mediastinitis (HR 2.4, 95% CI 1.1-5.6; P = 0.04) as independently associated with 1-year mortality.

CONCLUSIONS

Candida mediastinitis is a serious event after cardiac surgery and independently associated with 1-year mortality. Further studies are needed to determine whether deaths are directly attributable to Candida mediastinitis.

Use of longitudinal rigid sternal fixation in prevention and treatment of wound complications among high-risk patients after cardiac surgery

BACKGROUND

Traditionally, wire cerclage closure has been used to reapproximate the sternum after cardiac surgery. Recent evidence suggests that rigid sternal fixation may reduce the risk of wound complications. The aim of this study was to analyze our 10-year experience with longitudinal rigid sternal fixation (LRSF) for prevention and treatment of wound complications in high-risk patients.

METHODS

We reviewed data from cardiac surgical database of patients who underwent LRSF, and compared their outcomes with conventional wire cerclage closure (CWS). Among these 319 patients were designated as having high-risk for the development of deep wound complications and received primary LRSF (treatment group). We matched their outcomes with 319 patients who met indications for LRSF however, underwent standard closure with CWC (control group).

RESULTS

Both groups were comparable regarding preoperative and intraoperative variables. The benefit observed among matched patients who had undergone LRSF was largely driven by a decreased rate of deep wound infections (0.63% vs. 3.45% vs., p < .01), 30-day mortality (1.57% vs. 5.96%) and hospital length (8.2 vs. 11.7 days) p < .05, respectively. A multivariate logistic regression analysis found four independent risk factors for the development of sternal dehiscence. Sternal healing evaluated by computerized tomography scan using 6-point scale at 3 months after surgery was superior in LRSF patients. Pain scores were significantly lower in LRSF patients as well.

CONCLUSIONS

In patients with an increased risk for sternal instability and wound infections after cardiac surgery, sternal reconstruction using LRSF is an effective technique to stabilize sternum for preventive and treatment purposes.

Incidence, types and outcomes of sternal wound infections after cardiac surgery in Saudi Arabia. A retrospective medical chart review

Objectives:

To determine the incidence, types, risk factors, identify organisms, and assess outcomes of surgical wound infections (SWIs) after cardiac surgery at a tertiary hospital in Riyadh, Saudi Arabia.

Methods:

This historical cohort study reviewed the chart of patients who underwent cardiac surgery at King Khalid University Hospital, Riyadh, Saudi Arabia between January 2009 and December 2014. The proforma contained personal data, comorbidities, type of surgery, microbiological analysis, and management outcomes.

Results:

A total of 1241 patients were enrolled in the study comprising 1,032 (83.2%) men and 209 (16.8%) women. Forty (3.2%) patients developed SWI, of which 32 (2.5%) were superficial and 8 (0.7%) were deep. Gender, obesity, diabetes mellitus, non-use of statins, and coronary artery bypass graft (CABG) surgery were not significant predictors of infection in the study. Methicillin-susceptible Staphylococcus aureus was isolated predominantly in 45%, followed by Klebsiella and Pseudomonas species. Methicillin-resistant Staphylococcus aureus, Enterococcus faecium, and extended β-lactamase-producing gram-negative organisms were pathogens isolated in last 3 years of the review. Simple and vacuum assisted closure therapies led to complete resolution in 32 (80%) patients, while 8 (20%) developed sternal osteomyelitis. All patients survived except one with a deep SWI who died of uncontrolled sepsis.

Conclusion:

Despite the low incidence of postoperative SWIs, the risk of sternal osteomyelitis development persists. Meticulous choice of CABG components and appropriate postoperative management, especially detecting early signs of SWI could contribute to lower its incidence and complications.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Background

New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed.

Methods

Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis.

Results

Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups.

Conclusions

Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Wire Cerclage Versus Cable Closure After Sternotomy for Dehiscence and DSWI: A Systematic Review and Meta-Analysis

OBJECTIVE

Cable closure has been introduced as a potential alternative to traditional wire cerclage (WC) for closure of median sternotomy. To evaluate whether cable closure improves patient outcomes, we conducted a systematic review and meta-analysis of the literature.

METHODS

Ovid versions of Medline and Embase, and Google Scholar were used for the literature search. This yielded 7 studies (n = 2,758), which compared traditional WC to cable closure systems. Outcomes included deep sternal wound infection, sternal dehiscence, postoperative pain score, and sternal wound infection.

RESULTS

We found significantly lower incidence of sternal dehiscence for cable closure compared to WC (risk ratio [RR] 0.14, 95% confidence interval [CI]: 0.03 to 0.59, P < 0.01, I ² = 0%) but no difference in DSWI (RR 0.97, 95% CI: 0.39 to 2.42, P = 0.95, I ² = 33%). Cable closure was also associated with lower pain when compared with the WC group (mean difference -1.04 points, 95% CI: -1.89 to -0.19, P = 0.02, I ² = 87%).

CONCLUSIONS

This study suggests that cable closure results in less incidence of sternal dehiscence and pain compared to WC. Nonetheless, there remains a limited number of studies on this topic and further high-quality studies are required to confirm the results of this meta-analysis.

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Background:

Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon.

Methods:

Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space.

Results:

Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities.

Conclusion:

Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Vacuum-Assisted Closure for the Treatment of Deep Sternal Wound Infection After Pediatric Cardiac Surgery

OBJECTIVES

Vacuum-assisted closure is being increasingly used to treat deep sternal wound infection following cardiac surgery, but most of the data refer to adults. This study investigated the safety and efficacy of vacuum-assisted closure in pediatric patients.

DESIGN

Retrospective file review.

SETTING

Tertiary pediatric medical center.

PATIENTS

All children with deep sternal wound infection treated with vacuum-assisted closure in 2003-2016.

INTERVENTIONS

Epidemiological, clinical, and microbiological data were collected from the medical records.

MEASUREMENTS AND MAIN RESULTS

The cohort included 50 patients (0.9% of cardiac patients operated during the study period) of median age 6.5 months (interquartile range, 2-12.75 mo; range, 1 wk to 14 yr) and median weight 5.1 kg (interquartile range, 4-9.75 kg). The most frequent heart defects were tetralogy of Fallot (22%) and ventricular septal defect (20%); 38% of patients had cyanotic heart disease. Deep sternal wound infections appeared a median of 10 days postoperatively (interquartile range, 7-14 d; range 3-100 d). Vacuum-assisted closure was applied a median of 13 days postoperatively (interquartile range, 10-18.5 d; range, 5-103 d) for a median duration of 10 days (interquartile range, 7-13.25 d; range, 1-21 d). Wound cultures were positive in 48 patients (96%); most isolates were Gram-positive (76%). The main bacterial pathogen was methicillin-susceptible Staphylococcus aureus (61%). Most patients were treated with cloxacillin for a median of 38 days (interquartile range, 28-42 d; range, 9-189 d). There were no statistically significant differences in clinical or treatment characteristics between bacteremic (56%) and nonbacteremic patients. Compared with older patients, infants less than 3 months old (36%) had a significantly longer hospitalization time (41 vs 25 d; p = 0.001) and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category (3 vs 2; p = 0.003). All cases except one (contact dermatitis) were uneventful. In 10 patients, wounds were closed surgically after vacuum-assisted closure. Two patients required a pectoralis flap, both treated before 2005. One of the two deaths was infection-related.

CONCLUSIONS

Vacuum-assisted closure is a feasible treatment option of deep sternal wound infection after pediatric cardiac surgery and was not associated with independent morbidity.

Utility of FDG-PET/CT for the Detection and Characterization of Sternal Wound Infection Following Sternotomy

Purpose

FDG-PET/CT has the potential to play an important role in the diagnosis of sternal wound infections (SWI). The purpose of this study was to analyze the diagnostic accuracy of FDG-PET/CT for SWI in patients following sternotomy.

Methods

We performed a single-center, retrospective analysis of patients who had undergone median sternotomy and FDG-PET/CT imaging. The gold standard consisted of positive bacterial culture and/or the presence of purulent material at surgery. Qualitative patterns of sternal FDG uptake, SUV_max, and associated CT findings were determined, and an imaging scoring system was developed. The diagnostic performances were studied in both the recent (≤ 6 months between sternotomy and imaging) and remote surgery phase (> 6 months).

Results

A total of 40 subjects were identified with 11 confirmed SWI cases. Consensus interpretation was associated with a sensitivity of 91% and specificity of 97%. Combination of uptake patterns yielded an AUC of 0.96 while use of SUVmax yielded an AUC of 0.82.

Conclusions

Results suggest that FDG-PET/CT may be useful for the diagnosis of SWI with optimal diagnostic accuracy achieved by identifying specific patterns of uptake. SUV_max can be helpful in assessing subjects with remote surgery, but its use is limited in the context of recent surgery. Further studies are required to confirm these results.

Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†

OBJECTIVES

The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction.

METHODS

We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete.

RESULTS

The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years.

CONCLUSIONS

Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.

Concordance between superficial swab and deep sampling in post-sternotomy mediastinitis: Single center experience

OBJECTIVES

Deep sampling (DS) is the gold standard for microbiological diagnosis of post-sternotomy mediastinitis (PSM), however superficial swab (SS) are frequently performed in some centers and antibiotherapy initiated base on their results. We analysed the concordance between superficial swab and deep sampling in PSM.

MATERIALS AND METHODS

We analysed retrospectively patients with a PSM between 2010 and 2014 at Saint-Luc University hospital (Belgium). We considered that there was a concordance between SS and DS when the same microorganism was found in the two sampling method in each patient. Patients were stratified in six groups according to microbiology results as Staphylococcus Aureus (SA) sensitive or resistant, coagulase negative Staphylococcus (CoNS), Gram negative bacilli (GNB), other Gram positive bacteria (GPB) and fungi.

RESULTS

Thirty-six patients were included. Twenty-five men (69%) and a mean age of 66 years old. The overall concordance between SS and DS was 57%. SA and GNB showed high concordance (100% and 85.7% respectively). For the other groups the concordance was low. The sensitivity and specificity of SS was 97% and 33% respectively. The PPV and NPV of superficial swab was 96% and 50% respectively.

CONCLUSION

Microbiological results from SS, even with flocked swabs, except for SA and GNB have low concordance with those obtained from deep sampling. Our data confirm that in PSM, deep sampling is the gold standard for microbiological assessment.

Dressings used to prevent surgical site infection in the postoperative period of cardiac surgery: integrative review

OBJECTIVE

To identify and describe which dressings are recommended to prevent surgical site infection in hospitalized adult patients after cardiac surgeries.

METHOD

Integrative review carried out in the databases MEDLINE, LILACS, CINAHL, Web of Science, Cochrane and Scopus. Studies related to dressing in the postoperative period of cardiac surgery were selected.

RESULTS

Seven articles were included, with the following dressings: negative pressure wound therapy, silver nylon dressing, transdermal delivery of continuous oxygen and impermeable adhesive drape. The dressings that led to reduction of infection were negative pressure and silver nylon dressings.

CONCLUSION

It was not possible to identify which dressing is most recommended, however, some studies show that certain types of dressings were related to the reduction of infection. Clinical trials with a rigorous methodological design and representative samples able to minimize the risk of bias should be conducted to evaluate the effectiveness of dressings in the prevention of surgical site infection.

From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery

Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.

Coronary artery bypass graft surgery complications: A review for emergency clinicians

INTRODUCTION

Coronary artery bypass graft (CABG) surgery remains a high-risk procedure, and many patients require emergency department (ED) management for complications after surgery.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post-CABG surgery complications.

DISCUSSION

While there has been a recent decline in all cardiac revascularization procedures, there remains over 200,000 CABG surgeries performed in the United States annually, with up to 14% of these patients presenting to the ED within 30 days of discharge with post-operative complications. Risk factors for perioperative mortality and morbidity after CABG surgery can be divided into three categories: patient characteristics, clinician characteristics, and postoperative factors. Emergency physicians will be faced with several postoperative complications, including sternal wound infections, pneumonia, thromboembolic phenomena, graft failure, atrial fibrillation, pulmonary hypertension, pericardial effusion, strokes, renal injury, gastrointestinal insults, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary surgical team is needed, which improves patient outcomes. This review provides several guiding principles for management of acute complications. Understanding these complications and an approach to the management of hemodynamic instability is essential to optimizing patient care.

CONCLUSIONS

Postoperative complications of CABG surgery can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Early surgical consultation is imperative, as is optimizing the patient's hemodynamics, including preload, heart rate, cardiac rhythm, contractility, and afterload.

Current perspectives on diagnosis and management of sternal wound infections

Deep sternal wound infection (DSWI), also known as mediastinitis, is a serious and potentially fatal condition. The diagnosis and treatment of DSWI are challenging. In this current narrative review, the epidemiology, risk factors, diagnosis, and surgical and antimicrobial management of DSWI are discussed. Ideally, the management of DSWI requires early and sufficient surgical debridement and appropriate antibiotic therapy. When foreign material is present, biofilm-active antibiotic therapy is also needed. Because DSWI is often complex, the management requires the involvement of a multidisciplinary team consisting of cardiothoracic surgeons, plastic surgeons, intensivists, infectious disease specialists, and clinical microbiologists.

Rigid Plate Fixation Versus Wire Cerclage for Sternotomy After Cardiac Surgery: A Meta-Analysis

BACKGROUND

Traditionally, wire cerclage has been used to reapproximate the sternum after sternotomy. Recent evidence suggests that rigid plate fixation for sternal closure may reduce the risk of sternal complications.

METHODS

The Medline and Embase databases were searched from inception to February 2017 for studies that compared rigid plate fixation with wire cerclage for cardiac surgery patients undergoing sternotomy. Random effects meta-analysis compared rates of sternal complications (primary outcome, defined as deep or superficial sternal wound infection, or sternal instability), early mortality, and length of stay (secondary outcomes).

RESULTS

Three randomized controlled trials (n = 427) and five unadjusted observational studies (n = 1,025) met inclusion criteria. There was no significant difference in sternal complications with rigid plate fixation at a median of 6 months' follow-up (incidence rate ratio 0.51, 95% confidence interval [CI]: 0.20 to 1.29, p = 0.15) overall, but a decrease when including only patients at high risk for sternal complications (incidence rate ratio 0.23, 95% CI: 0.06 to 0.89, p = 0.03; two observational studies). Perioperative mortality was reduced favoring rigid plate fixation (relative risk 0.40, 95% CI: 0.28 to 0.97, p = 0.04; four observational studies and one randomized controlled trial). Length of stay was similar overall (mean difference -0.77 days, 95% CI: -1.65 to +0.12, p = 0.09), but significantly reduced with rigid plate fixation in the observational studies (mean difference -1.34 days, 95% CI: -2.05 to -0.63, p = 0.0002).

CONCLUSIONS

This meta-analysis, driven by the results of unmatched observational studies, suggests that rigid plate fixation may lead to reduced sternal complications in patients at high risk for such events, improved perioperative survival, and decreased hospital length of stay. More randomized controlled trials are required to confirm the potential benefits of rigid plate fixation for primary sternotomy closure.

Latitude of the study place and age of the patient are associated with incidence of mediastinitis and microbiology in open-heart surgery: a systematic review and meta-analysis

Objective

We aimed to summarize the pooled frequency of mediastinitis following open-heart surgery caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria.

Design

This study was a systematic review and a meta-analysis of prospective and retrospective cohort studies.

Materials and methods

We searched the literature, and a total of 97 cohort studies were identified. Random-effect model was used to synthesize the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses, considering study and patient-level variables. Small-study effect was evaluated.

Results

Substantial heterogeneity was present. The estimated incidence of mediastinitis evaluated from 97 studies was 1.58% (95% confidence intervals [CI] 1.42, 1.75) and that of Gram-positive bacteria, Gram-negative bacteria, and MRSA bacteria evaluated from 63 studies was 0.90% (95% CI 0.81, 1.21), 0.24% (95% CI 0.18, 0.32), and 0.08% (95% CI 0.05, 0.12), respectively. A meta-regression pinpointed negative association between the frequency of mediastinitis and latitude of study place and positive association between the frequency of mediastinitis and the age of the patient at operation. Multivariate meta-regression showed that prospective cohort design and age of the patients and latitude of study place together or in combination accounted for 17% of heterogeneity for end point frequency of mediastinitis, 16.3% for Gram-positive bacteria, 14.7% for Gram-negative bacteria, and 23.3% for MRSA bacteria.

Conclusion

Evidence from this study suggests the importance of latitude of study place and advanced age as risk factors of mediastinitis. Latitude is a marker of thermally regulated bacterial virulence and other local surgical practice. There is concern of increasing risk of mediastinitis and of MRSA in elderly patients undergoing sternotomy.

Wound complications and surgical events in de novo heart transplant patients treated with everolimus: Post-hoc analysis of the SCHEDULE trial

OBJECTIVES

The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen.

MATERIALS AND METHODS

A total of 115 patients (mean age 51 ± 13 years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention.

RESULTS

There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5 years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients.

CONCLUSION

De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.

Vancomycin pharmacokinetic and pharmacodynamic models for critically ill patients with post-sternotomy mediastinitis

BACKGROUND AND OBJECTIVE

Vancomycin is commonly used to treat serious methicillin-resistant staphylococcal infections, especially post-sternotomy mediastinitis (PSM). However, information on pharmacokinetics and pharmacodynamics in intensive care unit (ICU) patients remains scarce. We conducted vancomycin pharmacokinetic-pharmacodynamic modeling for ICU patients with PSM.

METHODS

This cohort study included 30 consecutive patients who received multiple vancomycin doses during primary closed drainage of PSM with Redon catheters, targeting serum drug trough concentrations of 25-35 mg/L, and generating 359 serum vancomycin concentration-time values for analysis. Population pharmacodynamics served to describe the withdrawal of Redon catheters, i.e., the probability of in-ICU cure.

RESULTS

Vancomycin pharmacokinetics corresponded to a two-compartment open model with first-order elimination kinetics. Mean [between-subject variability] population estimates were 1.91 (men)/1.25 (women) [0.28] L/h for vancomycin elimination, with intercompartmental clearance of 5.71 [1.01] L/h, and respective central and peripheral distribution volumes of 21.9 and 68 [0.53] L. Vancomycin clearance increased with body weight and declined with severity at ICU admission and serum creatinine (SCr), thereby allowing the prediction of the vancomycin plateau. Intercompartmental clearance decreased with diabetes mellitus (-70 %). The probability of withdrawing all Redon catheters (patient cured) was dependent only on the area under the concentration-time curve to minimum inhibitory concentration (AUC/MIC) exposures ratio in plasma. Neither preoperative factors, antistaphylococcal co-treatments, nor the initial number of Redon catheters significantly influenced this probability. The AUC/MIC exposures ratio had no significant effect on SCr levels.

CONCLUSION

These modeling analysis results identified five clinically relevant covariates that influenced vancomycin pharmacokinetics and might achieve better individualization of vancomycin dosing for methicillin-resistant staphylococcal PSM in ICU patients.

Blood versus crystalloid cardioplegia for pediatric cardiac surgery: a meta-analysis

OBJECTIVE

Blood and crystalloid cardioplegia are the main myocardial protective solutions used in pediatric cardiac surgery. However, the effectiveness of these two solutions on myocardial metabolism, reperfusion injury and clinical outcomes in pediatric patients is still under debate. The purpose of this meta-analysis was to compare the efficacy of these two cardioplegia solutions in pediatric cardiac surgery.

METHODS

Keyword searches were performed on PUBMED, EMBASE and The Cochrane Library for randomized, controlled, clinical studies which were primarily comparing blood and crystalloid cardioplegia in pediatric cardiac surgery and provided data of postoperative cardiac troponin I (cTnI), lactate, mechanical ventilation time, length of intensive care unit (ICU) stay and inotropic support. Databases were searched from 1966 to June 2013 and were restricted to peer-reviewed English language publications of human subjects. We summarized the combined results of the data as mean difference (MD, when outcome measurements were made on the same scale) or standard mean difference (SMD, when the studies assess the same outcome with different scales), with 95% confidence intervals.

RESULTS

Five studies were identified, with a total of 323 patients. Lactate level after cardiopulmonary bypass (CPB) was significantly lower after blood cardioplegia compared with crystalloid cardioplegia (SMD 1.09, 95%CI 0.12 to 2.06, p=0.03); cTnI release postoperatively at 4-6 h (MD 0.92 ng/ml, 95%CI -0.13 to 1.97, p=0.09), 12 h (MD 0.2 ng/ml, 95% CI -0.43 to 0.84, p=0.53) and 24 h (MD 0.98 ng/ml, 95%CI -0.26 to 2.22, p=0.12) was not significantly different between the groups; ventilation duration (MD 5.15 hours, 95%CI -7.51 to 17.81, p=0.42) and length of ICU stay (SMD -0.3, 95%CI -0.80 to 0.21, p=0.25) were not significantly different between the groups either.

CONCLUSION

Myocardial metabolism was better in the blood cardioplegia group compared with the crystalloid cardioplegia group. However, there was no evidence of improvement in myocardial damage or clinical outcome for either cardioplegia solution.

Vacuum-assisted closure system in treatment of postoperative mediastinitis

Objectives

Post-cardiac surgery mediastinitis is a serious complication with high morbidity and high financial costs. Using a vacuum-assisted closure system is the established line of treatment for mediastinitis, which improves outcome, especially in the high-risk group of patients.

Methods

From January 2007 to April 2011, a retrospective study was carried out to evaluate the outcome of vacuum-assisted closure in the treatment of postoperative mediastinitis.

Results

There were 34 patients; 27 were male and 7 female. Mean time from infection to vacuum-assisted closure was 3.34 ± 1.10 days. The duration of vacuum-assisted closure was 6.51 ± 1.85 days (3-9 days). The mean amount of discharge was 759.60 ± 175.28 mL (range, 354–990 mL). Of the 34 patients, 21 (61.76%) had direct surgical wound closure and 13 (41.16%) had re-wiring. Two patients had bilateral pectoral flaps. One patient had chronic fistula formation, and one had a tear in the right ventricle. Mean hospital stay was 11.28 ± 2.09 days (range, 6–16 days).

Conclusion

Vacuum-assisted closure therapy is a safe, reliable, and cost-effective modality of treatment for postoperative mediastinitis. It improves the outcome and can be combined with other modalities of conventional treatment, especially in high-risk groups such as the elderly or patients with diabetes.

Skeletonized internal thoracic artery is associated with lower rates of mediastinitis in elderly undergoing coronary artery bypass grafting surgery

BACKGROUND AND OBJECTIVES

Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. The aim of this study is to identify which option of harvesting internal thoracic artery (ITA), pedicled or skeletonized, is associated with lower rates of mediastinitis after coronary artery bypass grafting surgery (CABG) in elderly, in the Division of Cardiovascular Surgery of PROCAPE.

METHODS

Retrospective study of 160 elderly who underwent consecutive CABG between May 2007 and June 2011. Eleven preoperative variables, four intraoperative variables and eight postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated between two groups: CABG with skeletonized ITA (n=80) and pedicled ITA (n=80). Univariate and multivariate logistic regression analyses were applied.

RESULTS

The incidence of mediastinitis was 6.8% (n=11), with a lethality rate of 54.5% (n=6). The skeletonized ITA group were more exposed than pedicled ITA group to obesity (n=12 vs. n=4; 15% vs. 5%; P=0.035) and multiple transfusions (n=25 vs. n=11; 31.2% vs. 13.7%; P=0.008). The pedicled ITA group presented a greater risk of mediastinitis after CABG than skeletonized ITA group (n=10 vs. n=1; 12.5% vs. 1.2%; Unadjusted OR 11.3; 95% CI 1.4 - 241.5; P=0.008). In multivariate analysis, this difference maintained statistically significant (Adjusted OR 5.2; 95% CI 1.5-495.8; P=0.012), being considered an independent association.

CONCLUSIONS

We suggest that elderly should be considered for strategies to minimize risk of infection. In elderly that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Elderly should always be considered for use of skeletonized ITA.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment

Background

The aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery.

Methods

Between January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student’s test and Fisher’s exact test.

Results

The 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group.

Conclusion

Negative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

Evolution in the treatment of mediastinitis: single-center experience

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979–1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995–2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002–2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

Role of vacuum in methicillin-resistant deep sternal wound infection

Between January 2002 and January 2009, 39 patients with post-cardiotomy staphylococcal deep sternal wound infection were treated primarily by a vacuum-assisted closure method (group A). Results were compared with those of 30 patients with staphylococcal deep sternal wound infection who received closed mediastinal irrigation with antibiotics (group B). The prevalence of methicillin-resistance was similarly high in both groups (64.1% in A, 56.7% in B). One group B patient died during treatment. The median healing time was significantly shorter at 13 days in group A (mean, 13.5 +/- 3.2 days) compared to 18 days (mean, 21.2 +/- 16.4 days) in group B. Deep sternal wound infection did not recur after vacuum treatment, while 7 (24%) patients in group B suffered a recurrence. Hospital stay was significantly shorter in group A (median, 30.5 days; mean, 32.2 +/- 11.3 days vs. median, 45 days; mean, 49.2 +/- 19.3 days). The significantly shorter healing time with vacuum-assisted closure was confirmed in both methicillin-sensitive (12 vs. 17 days) and methicillin-resistant infections (14 vs. 21 days). Hospital stay remained significantly shorter in group A (35 vs. 46 days) when only methicillin-resistant deep sternal wound infection was considered.

Vacuum-assisted closure with a portable system for treatment of poststernotomy mediastinitis

The patient was a 50-year-old man with diabetes who was on insulin. Complications of mediastinitis developed after coronary bypass surgery, which had been performed for unstable angina. Upon hospital admission, the patient was treated with antibiotics, and the wound was cleaned on a daily basis. However, because the patient's fever persisted, the wound was completely opened surgically and found to be deep and large. Because the patient's condition was relatively stable, minimally invasive vacuum-assisted closure was selected. We fabricated a portable vacuum-assisted closure system that imposed few limitations on individual movement. Vacuum-assisted closure treatment resulted in both rapid abatement of fever and improved granulation. Dressings were changed once a week; the wound was closed 4 weeks after vacuum-assisted closure and healed completely. Vacuum-assisted closure may be an effective therapy for postoperative mediastinitis, and our portable vacuum-assisted closure system may significantly reduce patient distress as well as direct medical care.

Thoracic vertebrectomy and spinal reconstruction via anterior, posterior, or combined approaches: clinical outcomes in 91 consecutive patients with metastatic spinal tumors

OBJECT

Adequate decompression of the thoracic spinal cord often requires a complete vertebrectomy. Such procedures can be performed from an anterior/transthoracic, posterior, or combined approach. In this study, the authors sought to compare the clinical outcomes of patients with spinal metastatic tumors undergoing anterior, posterior, and combined thoracic vertebrectomies to determine the efficacy and operative morbidity of such approaches.

METHODS

A retrospective review was conducted of all patients undergoing thoracic vertebrectomies at a single institution over the past 7 years. Characteristics of patients and operative procedures were documented. Neurological status, perioperative variables, and complications were assessed and associations with each approach were analyzed.

RESULTS

Ninety-one patients (mean age 55.5 +/- 13.7 years) underwent vertebrectomies via an anterior (22 patients, 24.2%), posterior (45 patients, 49.4%), or combined anterior-posterior approach (24 patients, 26.4%) for metastatic spinal tumors. The patients did not differ significantly preoperatively in terms of neurological assessments on the Nurick and American Spinal Injury Association Impairment scales, ambulatory ability, or other comorbidities. Anterior approaches were associated with less blood loss than posterior approaches (1172 +/- 1984 vs 2486 +/- 1645 ml, respectively; p = 0.03) or combined approaches (1172 +/- 1984 vs 2826 +/- 2703 ml, respectively; p = 0.05) but were associated with a similar length of stay compared with the other treatment cohorts (11.5 +/- 9.3 [anterior] vs 11.3 +/- 8.6 [posterior] vs 14.3 +/- 6.7 [combined] days; p = 0.35). The posterior approach was associated with a higher incidence of wound infection compared with the anterior approach cohort (26.7 vs 4.5%, respectively; p = 0.03), and patients in the posterior approach group experienced the highest rates of deep vein thrombosis (15.6% [posterior] vs 0% [other 2 groups]; p = 0.02). However, the posterior approach demonstrated the lowest incidence of pneumothorax (4.4%; p < 0.0001) compared with the other 2 cohorts. Duration of chest tube use was greater in the combined patient group compared with the anterior approach cohort (8.8 +/- 6.2 vs 4.7 +/- 2.3 days, respectively; p = 0.01), and the combined group also experienced the highest rates of radiographic pleural effusion (83.3%; p = 0.01). Postoperatively, all groups improved neurologically, although functional outcome in patients undergoing the combined approach improved the most compared with the other 2 groups on both the Nurick (p = 0.04) and American Spinal Injury Association Impairment scales (p = 0.03).

CONCLUSIONS

Decisions regarding the approach to thoracic vertebrectomy may be complex. This study found that although anterior approaches to the thoracic vertebrae have been historically associated with significant pulmonary complications, in our experience these rates are nevertheless quite comparable to that encountered via a posterior or combined approach. In fact, the posterior approach was found to be associated with a higher risk for some perioperative complications such as wound infection and deep vein thromboses. Finally, the combined anteriorposterior approach may provide greater ambulatory and neurological improvements in properly selected patients.

Predictors of mortality after muscle flap advancement for deep sternal wound infections

BACKGROUND

Deep sternal wound infection is a devastating complication following median sternotomy, with mortality rates reported from 1.0 to 36 percent. Several studies have evaluated the risk factors for the development of a deep sternal wound infection, but the factors predicting survival after debridement and muscle flap advancement are not well known.

METHODS

A retrospective chart review was performed from September of 1997 to January of 2004 on all patients referred to a single plastic surgeon for treatment of a deep sternal wound infection following median sternotomy for cardiovascular surgery. The authors collected cardiovascular operative and intensive care unit data and information regarding patient demographics, medical history, laboratory studies, and follow-up. Data were analyzed as possible prognostic factors.

RESULTS

During the collection period, a total of 8414 cardiovascular surgery cases were performed through a median sternotomy. Deep sternal wound infections were identified and treated with muscle flap advancement in 124 patients (1.5 percent). Most patients (90 percent) were treated with bilateral pectoralis major flap advancements. Eighty-five patients underwent debridement and muscle flap advancement as a single-stage procedure. There were 26 perioperative deaths (21 percent). Presternotomy end-stage renal disease, presternotomy chronic obstructive pulmonary disease, and prolonged poststernotomy mechanical ventilation were found to be significant independent predictors of mortality despite muscle flap advancement.

CONCLUSIONS

These data identify patients with deep sternal wound infections who may be at increased risk for mortality after debridement and muscle flap advancement. This information may help the patient, family, and surgeon modify medical management or surgical treatment of this devastating problem.

Topical negative pressure effects on coronary blood flow in a sternal wound model

Several studies have suggested that mediastinitis is a strong predictor for poor long-term survival after coronary artery bypass surgery (CABG). In those studies, several conventional wound-healing techniques were used. Previously, we have shown no difference in long-term survival between CABG patients with topical negative pressure (TNP)-treated mediastinitis and CABG patients without mediastinitis. The present study was designed to elucidate if TNP, applied over the myocardium, resulted in an increase of the total amount of coronary blood flow. Six pigs underwent median sternotomy. The coronary blood flow was measured, before and after the application of TNP (-50 mmHg), using coronary electromagnetic flow meter probes. Analyses were performed before left anterior descending artery (LAD) occlusion (normal myocardium) and after 20 minutes of LAD occlusion (ischaemic myocardium). Normal myocardium: 171.3 +/- 14.5 ml/minute before to 206.3 +/- 17.6 ml/minute after TNP application, P < 0.05. Ischaemic myocardium: 133.7 +/- 18.4 ml/minute before to 183.2 +/- 18.9 ml/minute after TNP application, P < 0.05. TNP of -50 mmHg applied over the LAD region induced a significant increase in the total coronary blood flow in both normal and ischaemic myocardium.

The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis--a single center experience with 54 patients

Deep sternal infections, also known as poststernotomy mediastinitis, are a rare but often fatal complication in cardiac surgery. They are a cause of increased morbidity and mortality and have a significant socioeconomic aspect concerning the health system. Negative pressure wound therapy (NPWT) followed by muscular pectoralis plasty is a quite new technique for the treatment of mediastinitis after sternotomy. Although it could be demonstrated that this technique is at least as safe and reliable as other techniques for the therapy of deep sternal infections, complications are not absent. We report about our experiences and complications using this therapy in a set of 54 patients out of 3668 patients undergoing cardiac surgery in our institution between January 2005 and April 2007.

Septic rupture of the ascending aorta after aortocoronary bypass surgery

We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient.

Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis

In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with M. pectoralis muscle flaps as treatment for deep sternal wound infections. Our group performed a retrospective analysis of 3630 consecutive cardiac surgical patients using median sternotomy from 11/2004 to 11/2007. After removing sternal wires, necrotic debris and potentially infective material, restabilisation of the sternum was performed and VAC therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Of the analysed patients 16 female and 29 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus odds ratio (OR 3.5), chronic obstructive pulmonary disease (COPD) (OR 2.9), use of bilateral mammarian artery (OR 2.0) and obesity (1.8). The median age of patients with deep sternal infections was similar to control patients. Staphylococcus epidermis was the most common pathogen (37.8%) followed by Enterococcus faecilis (22.2%) and Staphylococcus aureus (17.8). In 22.2% no pathogen could be detected. The 30 day mortality was 0%, the in-hospital mortality was 15.6%. The results of our studies demonstrate that vacuum therapy in conjunction with early and aggressive debridement is an effective strategy for treating poststernotomy mediastinitis. We consider pectoralis major muscle flap reconstruction as a safe technique and regard it as the primary choice for wound closure in poststernotomy mediastinitis.