Treatment approaches to complicated sternal wounds – a therapeutic algorithm

Following cardiac surgical procedures, mediastinitis is a rare complication, with an incidence of 1 to 3 percent, carrying a mortality of up to 50 percent. Several treatment options are available. We were able to develop an therapeutic algorithm, based on the experience of 6360 patients, operated between 11/2004 and 08/2009at the Mediclin Heart Institute Lahr/Baden. Out of these patients 97 (1.5%), 32 female and 65 male patients, mean age 68 years, suffered from deep sternal wound infection and were treated corresponding to our therapeutic algorithm, including 4 different treatment pathways due to the specification of the infection. Surgical steps consist of repetitive radical surgical debridement and restabilization of sternal structures dependent on the time interval following the initial surgical procedures, use of vacuum assisted closure therapy and plastic reconstruction using the pectoral muscle.

We focus a special interest in the sternal restabilization due to the elapsed time to the initial cardiac procedure (pathway III) to avoid damage of the right ventricle and mediastinal structures.

The most common risk factors were insulin depending diabetes mellitus, COPD, obesity and the use of bilateral mammarian artery.

30 day mortality was 3%, hospital mortality was 7.2%. This therapeutic approach was advantageous for our special patient subgroup. The pectoral muscle plasty shows excellent functional results and is a safe procedure used for early treatment of deep sternal interventions. The VAC therapy is employed as a bridging procedure.