Primary treatment of deep sternal wound infection after cardiac surgery: a survey of German heart surgery centers

Abstract

There are various primary treatment modalities of managing deep sternal wound infection (DSWI) following cardiac surgery, namely surgical debridement with primary reclosure in conjunction with irrigation, Vacuum-assisted closure (V.A.C. therapy, and primary or delayed flap closure. The purpose of this study was to assess whether there is consensus of the primary management of DSWI using one method as a single line therapy or a combination of these procedures. Therefore, a questionnaire with regards to the primary treatment modalities of DSWI was distributed to all 79 German heart surgery centers. All replied to the questionnaire. V.A.C. is used in 28/79 (35%) heart centers as the 'first-line' treatment, 22/79 (28%) perform primary reclosure in conjunction with a double-tube irrigation/suction system, and in 29/79 (37%) clinics both treatment options were used according to intraoperative conditions. Mostly, as a primary management of DSWI two treatment modalities are mainly in use: primary reclosure coupled with a double-tube suction/irrigation system and V.A.C. therapy. The current understanding is based purely on retrospective studies, not evidence-based medicine. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing these treatment modalities are pivotal to define evidence for patients presenting with DSWI.

Sternal closure techniques and postoperative sternal wound complications in elderly patients

“…The guidelines of the Center for Disease Control and Prevention provide the following definition of DSWI: (1) bacteria can be isolated from cultures of mediastinal tissue or fluid; (2) evidence of mediastinitis is seen during surgery; or (3) one of the following conditions; chest pain, sternal instability, or fever (>38 8C) are present and there is either purulent discharge from the mediastinum or bacteria can be isolated from a blood culture of drainage originating from mediastinal area. We applied the classification of DSWI based upon El Oakley and Wright (Type I: mediastinitis presenting within 2 weeks after operation in the absence of risk factors, Type II: mediastinitis presenting at 2-6 weeks after operation in the absence of risk factors; Type IIIA: mediastinitis type I in the presence of one or more risk factors; Type IIIB: mediastinitis type II in the presence of one or more risk factors; Type IVA: mediastinitis type I, II, or III after one failed therapeutic trial; Type IVB: mediastinitis type I, II, or III after more than one failed therapeutic trial; Type V: mediastinitis presenting for the first time more than 6 weeks after operation) [6].…”

The Use of Fibula Free Flap for Reconstruction of Anterior Chest Wall Full-Thickness Defects

“…Sternal dehiscence is an infrequent but serious complication that is often a precursor to mediastinitis. Median sternotomy complications occur in 0.5% to 5% of patients with 0.2% to 3% of patients developing mediastinitis [2,3]. Sternal dehiscence is the process of separation of the bony sternum, which often is accompanied by media stinitis (infection of the deep soft tissues).…”

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

“…[42] This procedure was considered effective according to a multicenter study. [43] However, this procedure can only be used in patients with intact pleura and it is not free from complications such as pleural rupture and fall of cardiac output. [44] In our study, VAC drain was useful to narrow the gap between debridement and flap surgery.…”