Ann Thorac Surg 1997;64:854-856
© 1997 The Society of Thoracic Surgeons
Case Report
Surgical Management of Persistent Mediastinitis After Coronary Bypass Grafting
Friedrich S. Eckstein, MD,
Johannes M. Albes, MD,
Michael J. Jurmann, MD,
Albertus M. Scheule, MD,
Sabine Raygrotzki, MD,
Michael Laniado, MD,
Gerhard Ziemer, MD
Division of Thoracic, Cardiac, and Vascular Surgery, Department of Surgery, and Division of Diagnostic Radiology, Department of Radiology, Eberhard-Karls-Universität, Tübingen, Germany
Accepted for publication April 29, 1997.
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Abstract
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Persistent mediastinitis despite primary revision, closed irrigation therapy, and additional secondary omental plasty is a life threatening situation in cardiac surgery. We managed this rare complication in one instance by sternectomy and hemirectus plasty as well as bilateral pectoralis plasty.
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Introduction
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Median sternotomy is the standard approach to the heart in cardiac surgery. Mediastinitis early after a cardiac operation with or without instability of the sternum is an infrequent but serious complication. It can be treated by rewiring of the sternum and closed mediastinal irrigation in combination with systemic antibiotic treatment [1]. If this measure fails and infection continues, the next surgical step might include omental plasty [2, 3]. At that time the complication has already become life-threatening. For the rare occasions when continuing mediastinitis persists after omental plasty, a radical surgical approach is mandatory, which generally includes sternal resection and the use of muscle flaps, such as transposition of the rectus or pectoralis muscles or both [4]. We report a staged approach to succesful surgical treatment of a persistent mediastinal infection after coronary artery bypass grafting.
A 70-year-old man with coronary artery disease underwent bypass grafting using the left internal mammary artery for the left anterior descending artery and a saphenous vein graft sequentally for the first and second marginal branch as well as the posterior interventricular coronary artery. The initial postoperative course was uneventful. However, a sternal instability developed 7 days postoperatively. The mediastinum was revised, the sternum was rewired, and a closed irrigation with 1% vancomycin/saline solution was administered. Because of elevated temperature and leukocytosis, prophylactic antibiotic treatment was started with ciprofloxacin and flucoxacillin intravenously, although no bacteria were identified in cultures of the debridement. Again the early postoperative course was uncomplicated. The irrigation fluid showed no evidence of bacterial growth in samples retrieved daily. After 7 days, the patient was transferred to another hospital without signs of clinical infection. The sternum was tight on examination and wound healing was unremarkable.
Ten days later the patient was readmitted to our institution with clinical signs of an infection. A contrast computed tomographic scan showed clear evidence of mediastinitis without signs of sternal instability. The median sternotomy was reopened and a debridement of the mediastinum and sternum was performed. An omental plasty with mediastinal transposition of the greater omentum was performed and again closed irrigation with 1% vancomycin/saline solution was started. At this time, a methicillin-resistant Staphylococcus aureus was finally identified in the mediastinal swab as well as in postoperative cultures of the irrigation fluid. Although antibiotic treatment with intravenous vancomycin was given, clinical signs of infection and positive cultures of the irrigation fluid persisted for another 16 days. Computed tomographic scan proved a persistent mediastinitis.
A third rethoracotomy was therefore carried out. The situs showed putrid masses in the anterior mediastinum and osteomyelitis of the entire sternum. The bypass grafts had not been affected as they were covered by the overlying viable omentum. A total sternectomy with removal of the costal cartilages was performed. The anterior mediastinum was then covered with the rectus muscle transposed from the right side because the left internal thoracic artery had been used for revascularization. During the transposition maneuver observation of continous bleeding from the distally transected epigastric artery served as control for preservation of an unrestricted blood flow into the muscle. Transposition of both pectoralis major muscles on internal pedicles based on the thoracoacromial arteries was carried out to achieve an additional sealing of the defect of the resected area.
Postoperatively, intravenous antibiotic treatment was performed with vancomycin and rifampicin. The patient was extubated on the first postoperative day. During the further course the patient recovered well and exhibited no signs of a persistent infection. Bacteriologic monitoring showed negative results after 2 weeks. Repeated control computed tomographic scan exhibited no evidence of mediastinitis or encapsulated abscesses in the operated field. The transposed muscles and the omentum were viable and well ingrown in the formerly infected mediastinum (Fig 1
). Antibiotic treatment was stopped after 4 weeks and the patient was discharged 66 days after the initial bypass operation. The wound had healed entirely and the anterior thorax had gained sufficient stability. One year after these events the patient continues to present himself in an excellent physical condition.
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Fig 1. . Postoperative contrast computed tomographic scan. (m. rectus abdom. = rectus abdominis muscle; mm. pectorales = pectoralis major muscle.)
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Comment
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Patients undergoing cardiac operations with median sternotomy are at risk for mediastinal wound complications. Major infectious complications are reported to occur in up to 2%. In coronary bypass grafting using the internal mammary artery they may occur in up to 8% of patients [5]. Reported mortality rates up to 29% [6] are caused by sepsis, osteomyelitis, dehiscence of the sternum, mediastinitis, pericarditis, infection of the great vessels, and occlusion of the bypass grafts. The common clinical signs of a sternal infection are symptoms such as fever, leukocytosis, persistent purulent drainage, pain, and sternal instability. In our institution we use a staged procedure depending on the extent of a mediastinal infection. Sternal instability with or without minor signs of an infection is treated by early sternal revision, closed irrigation with saline solution/vancomycin, and application of intravenous antibiotics. In cases of ongoing sternal infections we perform an early radical removal of necrotic tissue, omental transposition, and direct closure.
In the literature multiple approaches and a variety of procedures are described [2–4]. Postoperative drainage and closed irrigation is widely used as well as omental transposition to reduce morbidity and hospital stay [2, 3]. Muscle flaps as an adjunct to an omental plasty or alone are often applied to those patients with multiply fractured or necrotic sternal tissue and severe persistent mediastinitis. In those instances unilateral or bilateral pectoralis major muscle, latissimus dorsi, and rectus abdominis muscle flaps have been employed alone or in various combinations. Pedicled latissimus dorsi flaps were also successfully transposed to the sternum wound. Long-term results of coverage of infected median sternotomy wounds using one of these muscle transposition maneuvers also showed a significant reduction in morbidity, mortality, and length of hospital stay. Undisturbed healing was obtained in nearly all of these patients [4]. The approach to mediastinitis after cardiac operations appears to differ in the literature. Although Belcher and collegues [3] from London reported successful treatment of mediastinitis by means of primary omental plasty, Ringelman and coworkers [4] from Baltimore presented excellent results in a series of patients treated primarily with muscle flaps. The preferable maneuver, however, may depend on the particular cause of the condition as well as the individual surgeon's choice. In our experience mediastinitis could be controlled in almost all cases by rewiring and closed irrigation only, and rarely required secondary omental plasty. We believe that not all patients require an extensive procedure such as muscle transposition in the first place and recommend a staged approach according to the requirements of the patients. We continue to use this procedure as the final measure of a staged approach to the surgical management of complicated mediastinitis.
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Footnotes
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Address reprint requests to Dr Eckstein, Division of Thoracic, Cardiac, and Vascular Surgery, Department of Surgery, Eberhard-Karls-Universität Tübingen, Hoppe-Seyler-Str 3, 72076 Tübingen, Germany.
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References
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- Angelini GD, Lamarra M, Azzu AA, Bryan AJ. Wound infection following early repeat sternotomy for postoperative bleeding. An experience utilizing intraoperative irrigation with povidone iodine. J Cardiovasc Surg (Torino) 1990;31:793–5.[Medline]
- Colen LB, Huntsman WT, Morain WD. The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum. Plast Reconstr Surg 1989;84:936–41.[Medline]
- Belcher P, McLean N, Breach N, Paneth M. Omental transfer in acute and chronic sternotomy wound breakdown. Thorac Cardiovasc Surg 1990;38:186–91.[Medline]
- Ringelman PR, Vander-Kolk CA, Cameron D, Baumgartner WA, Manson PN. Long-term results of flap reconstruction in median sternotomy wound infections. Plast Reconstr Surg 1994;93:1208–14.[Medline]
- Culliford AT, Cunningham JN, 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;72:714–26.[Abstract]
- Milano CA, Kesler K, Archibald N, Sexton DJ, Jonas RH. Mediastinitis after coronary bypass graft surgery. Risk factors and long-term survival. Circulation 1995;92:2245–51.[Abstract/Free Full Text]
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Abstract
Introduction
