Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Journal of Cardiothoracic Surgery
Published in: Journal of Cardiothoracic Surgery 1/2017

Open Access 01-12-2017 | Review

Sternal reconstruction after post-sternotomy mediastinitis

Author: Pankaj Kaul

Published in: Journal of Cardiothoracic Surgery | Issue 1/2017

Login to get access

Abstract

Background

Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text.

Methodology and review

This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented.

Conclusions

Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.
Literature
1.
Bryer RH, Mills SA, Hudspeth AS, Johnston FR, Cordell ARA. Prospective study of sternal wound complications. Annals of thoracic. Surgery. 1984;37:412.
2.
Culliford AT, Cunningham JN Jr, Zeff RH, Isom OW, Teiko P, Spencer FC. Sternal and costochondral infections following open heart surgery. A review of 2594 cases. J Thorac Cardiovasc Surg. 1976;72:714.PubMed
3.
Cheung EH, Craver JM, Jones EL, Murphy DA, Hatcher CR Jr, Guyton RA. Mediastinitis after cardiac valve operations: impact upon survival. J Thorac Cardiovasc Surg. 1985;90:517.PubMed
4.
Lazar HL, Vander Salm T, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infection. J Thorac Cardiovasc Surg. 2016;152:962–72.CrossRefPubMed
5.
Wilson AP, Livesey SA, Treasure T, Gruneberg RN, Sturridge MF. Factors predisposing to wound infection in cardiac surgery: a prospective study of 517 patients. European Journal of Cardiothoracic Surgery. 1987;1:158.CrossRefPubMed
6.
Ottino G, De Paulis R, Pansini S, Rocca G, Tallone MV. Major sternal wound infection after open heart surgery: a multivariate analysis of risk factors in 2579 consecutive operative procedures. Annals of thoracic. Surgery. 1987;44:173–9.
7.
Sarr MG, Gott VL, Townsend TR. Mediastinal infection after cardiac surgery. Annals of thoracic. Surgery. 1984;38:415.
8.
Schimmer C, Reents W, Berneder S, Eigel P, Sezer O. Prevention of sternal dehiscence and infection in high risk patients: a prospective randomised multicentre trial. Annals of thoracic. Surgery. 2008;86:1897–904.
9.
Grabert S, Erlebach M, Will A, Lange R, Voss B. Unexpected results after sternal reconstruction with plates, cables and cannulated screws. Interact Cardiovasc Thorac Surg. 2016;22:663–7.CrossRefPubMedPubMedCentral
10.
Hassan M, Smith JM, Engel AM. Predictors and outcomes of sternal wound complications in patients after coronary artery bypass grafting. Am Surg. 2006;72:515–20.PubMed
11.
Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG. Risks of bilateral internal mammary artery bypass grafting. Annals of thoracic. Surgery. 1990;49:210.
12.
Reyna GC, Baca GGA, Concebida LEM, Sanchez GB, Villegas GP, Sanchez RA. Risk factors for mediastinitis and sternal dehiscence after cardiac surgery. Rev Esp Cardiol. 2006;59:130–5.CrossRef
13.
Demmy TL, Park SB, Liebler GA, Buckholder JA, Maher TD, Benckart DH. Recent experience with major sternal wound complications. Annals of thoracic. Surgery. 1990;49:458.
14.
Newman LS, Szezukowski LC, Bain RP, Perlino CA. Suppurative mediastinitis after open heart surgery; a case control study of risk factors. Chest. 1988;94:546.CrossRefPubMed
15.
Tiveron MG, Fiorelli AI, Mota EM, OSAV M. Preoperative risk factors for mediastinitis after cardiac surgery: assessment of 2768 patients. Brazilian Journal of Cardiovascular Surgery. 2012;27:0102–7638.CrossRef
16.
Weinstein AL, Chang MM, Argenziano M, Ascherman JA. Risk factors of infected sternal wounds versus sterile wound dehiscence. J Surg Res. 2016;200:400–7.CrossRefPubMed
17.
Ferrazi P, Allen R, Crupi G, Reyes I, Parenzan L, Maisonnet M. Reduction of infection after cardiac surgery: a clinical trial. Annals of thoracic. Surgery. 1986;42:321.
18.
Myerowitz PD, Caswell K, Lindsay WG, Nicoloff DM. Antibiotic prophylaxis for open heart surgery. J Thorac Cardiovasc Surg. 1977;73:625.PubMed
19.
Engelman R, Shahian D, Shemin R, et al. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: antibiotic choice. Annals of thoracic. Surgery. 2007;83:1569–76.
20.
Vander Salm TJ, Okike ON, Pasque MK, et al. Reduction of sternal infection by application of topical vancomycin. J Thorac Cardiovasc Surg. 1989;98:618–22.PubMed
21.
Frieberg O, Svedieholm R, Soderquist B, et al. Local gentamicin reduces sternal wound infections after cardiac surgery: a randomised controlled trial. Annals of thoracic. Surgery. 2005;79:153–61.
22.
Eklund AM, Valtonen M, Werkkala KA. Prophylaxis of sternal wound infections with gentamicin-collagen implant: a randomised controlled study in cardiac surgery. J Hosp Infect. 2005;59:108–12.CrossRefPubMed
23.
Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting. Annals of thoracic. Surgery. 2016;101:801–9.
24.
Reiss FC, Awwad N, Hoffmann B, Bader R, Helmold HYA. Steel band in addition to 8 wire cerclages reduces the risk of sternal dehiscence after median sternotomy. The Heart Surgery Forum. 2004;7:387–92.CrossRef
25.
Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high risk patients prevents mediastinitis. European Journal of Cardiothoracic Surgery. 2004;26:367–72.CrossRefPubMed
26.
Kay HR, Goodman LR, Teplick SK, Mundth ED. Use of computed tomography to assess mediastinal complications after median sternotomy. Annals of thoracic. Surgery. 1983;36:706.
27.
Gardlind B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery – microbiology and pathogenesis. European Journal of Cardiothoracic Surgery. 2002;21(5):825–30.CrossRef
28.
Rupprecht L, Schmid C. Deep sternal wound complications - an overview of old and new therapeutic options. Open J Cardiovasc Surg 2013;6:9–19.PubMedPubMedCentral
29.
Zec N, Donovan JW, Aufiero TX. Seizures in a patient treated with continuous povidone-iodine mediastinal irrigation. N Eng J Med 1992;326:1784.
30.
Campistol JM, Abad C, Nogue S, Bertram A. Acute renal failure in a patient treated by continuous povidone-iodine mediastinal irrigation. J Cardiovas Surg 1988;29:410–12.
31.
Moriaski A, Hosono M, Murakami T, Sakaguchi M, Suehiro Y. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg. 2016;23:397–402.CrossRef
32.
Debreneci T, Szerafin T, Galajda Z, Miskolczi S, Peterfly A. Results of vauum-assisted wound closure system in the treatment of sternotomy wound infections following cardiac surgery. Magyar Sebeszet. 2008;61:10.1556.
33.
Thurer RJ, Bognolo D, Vargas A, Isch JH, Kaiser GA. The management of mediastinal infection following cardiac surgery. An experience utilising continuous irrigation with povidone-iodine. J Thorac Cardiovasc Surg. 1974;68:962.PubMed
34.
Wu S, Wan F, Gao YS, Zhang Z, Zhao H. Sternal reconstruction of deep sternal wound infections following median sternotomy by single-stage muscle flaps transposition. Chinese medical science. Journal. 2014;29:208–13.
35.
Preminger BA, Yaghoobzadeh Y, Ascherman JA. Management of sternal wounds by limited debridement and partial pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach. Ann Plast Surg. 2014;72:446–50.CrossRefPubMed
36.
Eriksson J, Huljebrant I, Nettelblad H, Svedjeholm R. Functional impairement after treatment with pectoral muscle flaps because of deep sternal infection. Scand Cardiovasc J. 2011;45:174–80.CrossRefPubMed
37.
Cabbabe EB, Cabbabe SW. Surgical management of the symptomatic unstable sternum with pectoralis major muscle flaps. Plast Reconstr Surg. 2009;123:1495–8.CrossRefPubMed
38.
Tomos P, Lachanas E, Michail PO, Kostakis A. Alternative bipectoral muscle flaps for postoperative sternotomy medistinitis. Ann Thorac Surg. 2006;81:754–5.CrossRefPubMed
39.
Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous flaps in 114 consecutively treated patients: refinements in technique and outcome analysis. Plast Reconstr Surg. 2004;114:676–83.CrossRefPubMed
40.
Sung K, Jun TG, Park PW, Park KH, Lee YT. Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps. Ann Thorac Surg. 2004;77:1371–5.CrossRefPubMed
41.
Sung K, Niazi ZB, Salzberg CA, Permut LC. Vascularised muscle flaps and reoperative approach for complicated, dehisced sternal wounds in children. Ann Plast Surg. 1998;40:523–7.CrossRefPubMed
42.
Dosios T, Papadopoulos O, Mantas D, Georgiiou P, Asimacopoulos P. Scandanavian journal of plastic and reconstructive surgery and. hand surgery. 2003;37:220–4.
43.
Backer CL, Pensler JM, Tobin GR, Mavroudis C. Vascularised muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg. 1994;57:797.CrossRefPubMed
44.
Ascherman JA, Hugo NE, Sultan MR, Patsis MC, Smith CR. Single stage treatment of sternal wound complications in heart transplant recepients in whom pectoralis major myocutaneous advancement flaps were used. J Thorac Cardiovasc Surg. 1995;110:1030–6.CrossRefPubMed
45.
Li EN, Goldberg NH, Slezak S, Silverman RP. Split pectoral major flaps for mediastinal wound coverage: a 12 year experience. Ann Plast Surg. 2004;53:334–7.CrossRefPubMed
46.
Kuntscher MV, Mansouri S, Noack N, Hartmann B. Verstality of vertical rectus abdominis musculocutaneous flaps. Microsurgery. 2006;26:363–9.CrossRefPubMed
47.
Netscher DT, Eladoumikdachi F, Goodman CM. Rectus abdominis muscle flaps used successfully for median sternotomy wounds after ipsilateral internal mammary artery ligation. Ann Plast Surg. 2001;47:223–8.CrossRefPubMed
48.
Davison SP, Clemens MW, Armstrong D, Newton ED, Swartz W. Sternotomy wounds. Plast Reconstr Surg. 2007;120:929–34.CrossRefPubMed
49.
Lovich SF, Iverson LI, Young JN, Ennix CL, Harrell JE. Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection. Arch Surg. 1989;124:1192–4.CrossRefPubMed
50.
De Brabendere K, Jacobs TTD, Czapla J, La Meir M, Delavaux G. Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy. Tex Heart Inst J. 2012;39:367–71.
51.
Acarturk TO, Swartz WM, Luketich J, Quinlin RF, Edington H. Laparoscopically harvested omental flap for chest wall and intrathoracic reconstruction. Ann Plast Surg. 2004;53:210–6.CrossRefPubMed
52.
Salameh JR, Chock DA, Gonzalez JJ, Koneru S, Glass JL. Laparoscopic harvest of omental flaps for reconstruction of complex mediastinal wounds. Journal of Society of Laparoendoscopic Surgeons. 2003;7:317–22.
53.
Schroeyers P, Wellens F, Degrieck I, De Geest R, Van Praet F. Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental and muscle flaps surgery. European Journal of Cardiothoracic surgery. 2001;20:743–6.CrossRefPubMed
54.
Milano CA, Georgiade G, Muhlbaier LH, Smith PK, Wolfe WG. Comparison of omental and pectoralis flaps for poststernotomy mediastinitis. Ann Thorac Surg. 1999;67:377.CrossRefPubMed
55.
Parissis H, Al-Alao B, Soo A, Orr D, Young V. Risk analysis and outcome of deep mediastinal wound infections with specific emphasis to omental transposition. J Cardiothorac Surg. 2011;6:111.CrossRefPubMedPubMedCentral
56.
Pieri M, Muller M, Scandroglio AM, Pergantis P, Kretschmar A. Surgical treatment of mediastinitis with omentoplasty in ventricular assist device patients: report of referral centre experience. American Society for Artificial Internal Organs. 1992;62:666–70.CrossRef
57.
Dornseifer U, Kleeberger C, Ehrl D, Herter F, Ninkovic M. Arteriovenous loop-independent free flap reconstruction of sternal defects after cardiac surgery. J Reconstr Microsurg. 2016;32:506–12.CrossRefPubMed
58.
Kaul P, Qadri SSA, Riaz M. Chronic encapsulated mediastinal abscess presenting with remote cutaneous fistulisation 12 years after redo aortic valve replacement for prosthetic valve endocarditis. J Cardiothorac Surg. 2006;1:22.CrossRefPubMedPubMedCentral
59.
Telfer JR, Chapple DC, Powell BW. Metastatic colonic adenocarcinoma in a pedicled omental flap used for sternal reconstruction: a case report. Br J Plast Surg. 1996;49:67–9.CrossRefPubMed
60.
Meland NB, Arnold PG, Pairolero PC, Trastek VF. Refinements in intrathoracic use of muscle flaps. Clin Plast Surg. 1990;17:697–703.PubMed
61.
Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast Reconstr Surg. 1985;76:703–7.CrossRefPubMed
62.
Hakaka T, Berg L, Berg E, Makinen K, Sipola P. Repair of right ventricular free wall defect with a deepithelialized pedicled myocutaneous latissimus dorsi muscle flap. Ann Thorac Surg. 2005;80:2360–2.CrossRef
63.
Kaul P. Repeated successful surgical rescues of early and delayed multiple ruptures of ventricular septum, right ventricle and aneurysmal left ventricle following massive biventricular infarction. J Cardiothorac Surg. 2006;1:30.CrossRefPubMedPubMedCentral
64.
Dejesus RA, Paletta JD, Dabb RW. Reconstruction of the median sternotomy wound dehiscence using the latissimus dorsi myocutaneous flap. J Cardiovasc Surg. 2001;42:359–64.
65.
Taeger CD, Horch RE, Arkudas A, Schmitz M, Stubinger A. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery. 2016;36:121–7.CrossRefPubMed
66.
Wang J, Min P, Grasseti L, Lazzeri D, Zhang YX. Preliminary outcomes of distal IMAP and SEAP flaps for the treatment of unstable keloids subject to recurrent inflammation and infections in the lower sternal and upper abdominal areas. J Reconstr Microsurg. 2015;31:621–30.CrossRefPubMed
67.
Bravo FG, Schwarze HP. Free style local perforator flaps: concept and classification system. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2009;62:602–8.CrossRefPubMed
68.
Cooper L, Payne C. The use of novel inferomedial fasciocutaneous breast flaps to reconstruct a sternal dehiscence with concomitant soft tissue loss. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014;67:1762–3.CrossRefPubMed
69.
de Fontaine S, Devos S, Goldschmidt D. Reduction mammoplasty combined with pectoralis major muscle flaps for median sternotomy wound closure. Br J Plast Surg. 1996;49:220–2.CrossRefPubMed
70.
Pancholy B, Raman J. Chest wall reconstruction using sternal plating in patients with complex sternal dehiscence. Ann Thorac Surg. 2015;99:2228–30.CrossRefPubMed
71.
Kalab M, Karkosa J, Kaminek M, Santavy P. Transplantation of allogeneic bone graft in the therapy of massive post-sternotomy defects. Rozhl Chir. 2016;95:399–406.PubMed
72.
Lindsey JTA. Retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications. Plast Reconstr Surg. 2002;109:1882.CrossRefPubMed
73.
Izzadoost S, Withers EH. Sternal reconstruction with omental and pectoralis flaps:a review of 415 consecutive cases. Ann Plast Surg. 2012;69:296–300.CrossRef
74.
van Wingerden JJ, Lapid O, Boonstra PW, de Mol BA. Muscle flaps and omental flap in the management of deep sternal wound infection. Interact Cardiovasc Thorac Surg. 2011;13:179–87.CrossRefPubMed
75.
Kaye AE, Kaye AJ, Pahk B, Mckenna ML, Low DW. Sternal wound reconstruction : management in different cardiac populations. Ann Plast Surg. 2010;64:658–66.PubMed
76.
Spartalis E, Markakis C, Moris D, Lachanas E, Agathos E. Results of the modified bipectoral muscle flap procedure for post-sternotomy deep wound infection. Surg Today. 2016;46:460–5.CrossRefPubMed
Metadata
Title
Sternal reconstruction after post-sternotomy mediastinitis
Author
Pankaj Kaul
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Journal of Cardiothoracic Surgery / Issue 1/2017
Electronic ISSN: 1749-8090
DOI
https://doi.org/10.1186/s13019-017-0656-7

Other articles of this Issue 1/2017

Journal of Cardiothoracic Surgery 1/2017 Go to the issue

Research article

Impact of prosthesis–patient mismatch on short-term outcomes after aortic valve replacement: a retrospective analysis in East China

Research article

Postoperative air leak grading is useful to predict prolonged air leak after pulmonary lobectomy

Case report

Right ventricular outflow tract obstruction caused by right ventricular fibroma in a 5-month-old infant: a case report

Research article

Renal ultrasound provides low utility in evaluating cardiac surgery associated acute kidney injury

Research article

Minimally access via left anterior mini-thoracotomy for repair of adult subarterial ventricular septal defects

Case report

A rare case of biventricular myxoma