A Novel Management of Deep Sternal Wound Infection and Sternal Wall Stabilization - The 66th Annual Conference of the Israel Heart Society & The Israel Society of Cardiothoracic Surgery

Moris Topaz ¹ David Yakobi ³ Guy Topaz ⁷ Menachem Motiei ⁴ Rachel Popovtzer ⁴ Othaman Badir ³ Neta Zilony ⁴ Benny Zuckermann ³ Hagi Dekel ³ Alexey Migranov ³ Gideon Sahar ⁵ Menachem Matsa ⁵ Danna Egozi ⁶ Dani Fink ²

¹Department of Surgery, Shaare Zedek
²Department of Cardio Thoracic Surgery, Shaare Zedek
³Department of Cardio Thoracic Surgery, Wolfson Medical Center
⁴Faculty of Engineering, Bar-Ilan University
⁵Department of Cardio Thoracic Surgery, Soroka Hospital
⁶Department of plastic Surgery, Kaplan Hospital
⁷Department of Internal Medicine C, Meir Medical Center

Introduction: Mediastinitis is a life-threatening complication of deep sternal wound infection (DSWI) developing mainly following cardiac surgery. Current management concepts include long term antibiotic treatment, wide surgical debridement, vacuum-assisted closure therapy, reconstruction with vascularized soft tissue flaps, such as omentum or pectoralis muscle flaps, and sternal stabilization. This treatment approach is associated with significant procedure-related morbidity; complicated surgical procedures, prolonged antibiotic treatment, lengthy and high-cost hospitalization and mortality.

Methods: A novel conservative reconstructive approach involving limited debridement, en-bloc primary wound closure based-on the application of the TopClosure^® tension relief system (TRS), regulated oxygen-enriched and irrigation negative pressure-assisted wound therapy (ROI-NPT) and a unique method of continuous, in-situ-targeted administration of ultra-high concentration antibiotics (CITA), directed into the infected sternal cavity, is presented.

Results: Primary closure of DSWIs was achieved in 20 of 28 (71%) patients. Wound closure failed in 8 (24%) cases (reinfection, fistulas and wound dehiscence), 5 (18%) patients died within 30 days of reconstruction, from reasons not directly related to surgery. No major bleeding or sepsis events were related to surgery. All sternal wires were removed and substituted with TRS, together with limited debridement of necrotic sternal bone. None of the patients required further chest wall stabilization.

Conclusion: This novel approach, applying combined CITA-ROINPT for wound decontamination, together with TRS for early or immediate primary wound closure and chest wall stabilization, reform DSWI management. The method effectively combat wound infection, eliminates the traditional need for a lengthy process of granulation tissue growth by conventional vacuum treatment, can substitute for complex flap closure and may provide durable sternal stabilization for wound closure through a simplified surgical procedure and short hospitalization.

Keywords – Deep sternal wound infection, post-sternotomy mediastinitis, immediate primary wound closure, CITA, ROINPT, TRS