Bilateral pectoral myocutaneous advancement flaps and anatomic sternal wound reconstruction in cyanotic infants with mediastinitis

Safety of neonatal sternal wound reconstruction after open heart surgery

An open sternal wound is a dreaded complication after open heart surgery for neonatal congenital cardiac anomalies. Vascularised muscle flap reconstruction of sternal wound defects, to prevent life-threatening mediastinal infections, is the standard of care in adults and children. However, there is paucity of published literature regarding the safety of this technique in neonates. We describe a successful operative technique for complex reconstruction of an open heart sternal defect on a neonatal male patient. On 6 months postoperative follow-up, we identified an issue with sternal instability. Patient underwent a subsequent operation for reinforcement of the sternal wound repair with Vicryl mesh. The authors report safety of using three separate vascularised muscle flaps in a single neonatal operation. Long-term follow-up of the sternal wound reconstruction is warranted to determine need for secondary procedures.

Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study

BACKGROUND AND AIM

Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented.

METHODS AND MATERIALS

A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival.

RESULTS

Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up.

CONCLUSIONS

Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.

Vascularisation of pectoralis maior myocutaneous flap: anatomical study in human fetuses and cadavers

Pectoral major flap is one of most frequently used flaps in head and neck reconstruction. The wide attractiveness of this flap is based on secure vascular stalk made from pectoral branch of thoracoacromial artery. The aim of study was to analyze the variations in vascular supply of pectoral major muscle. The investigation was performed on 30 fetuses from 20 to 36 gestation week both gender. For determining vascular network the samples injected with barium sulphate were subjected to Spalteholtz technique, and on 30 fresh cadavers where and we performed injection of Metilen blue 1% in pectoral branch of thoracoacromial artery. In 87% we found one pectoral branch and in 13 % two branches for pectoral muscle were found. Before entering the muscle, pectoral branch is dividing in two terminal branches (67%). In all cases lateral part of pectoral muscle is supplied by branch of lateral thoracic artery. The average area of dyed skin was 13 x 20 cm in region between III and VI rib and from parasternal line to anterior axillar line. The average distance of most distal part of dyed skin to midclavicular point was 24 cm. The pectoral branch of thoracoactomial artery obtains main blood supply for pectoral major muscle mass and despite of anatomical variations can be defined as main pedicle for musculocutaneous flap. Dyed skin confirms that pectoral major flap has defined skin territory sufficient for reconstructions in head and neck area.

Repeated successful surgical rescues of early and delayed multiple ruptures of ventricular septum, right ventricle and aneurysmal left ventricle following massive biventricular infarction

A 58 year old man underwent 6 surgical interventions for various complications of massive biventricular myocardial infarction over a period of 2 years following acute occlusion of a possibly "hyperdominant" left anterior descending coronary artery. These included concomitant repair of apicoanterior post-infarction VSD and right ventricular free wall rupture, repeat repair of recurrent VSD following inferoposterior extension of VSD in the infarcted septum 5 weeks later, repair of delayed right ventricular free wall rupture 4 weeks subsequently, repair of a bleeding left ventricular aneurysm eroding through left chest wall 16 months thereafter, repair of right upper lobe lung tear causing massive anterior mediastinal haemorrhage, mimicking yet another cardiac rupture, 2 months later, followed, at the same admission, 2 weeks later, by sternal reconstruction for dehisced and infected sternum using pedicled myocutaneous latissimus dorsi flap. 5 years after the latissimus myoplasty, the patient remains in NYHA class 1 and is leading a normal life.

Mediastinal wound infections following pediatric cardiac surgery

Deep sternal wound infections in children and neonates occur at approximately the same incidence as in adults. The organisms responsible are generally Staphylococcal species. The risk factors in adults include diabetes mellitus, the use of internal mammary artery grafts for bypass conduits, and other factors which clearly relate to age and the nature of the operations performed. In children the risk factors include leaving the sternum open following repair, nasal colonization with Staphylococcal species, need for re-exploration for bleeding, and others. Although conventional therapy for this complication is similar to what is proposed for adults, recently interest has been established in treating with debridement and primary closure of the sternum.