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Ann Thorac Surg 2002;74:1596-1600
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery

^a Departments of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
^b Plastic and Reconstructive Surgery, University of Vienna, Vienna, Austria

Accepted for publication June 26, 2002.

* Address reprint requests to Dr Fleck, Department of Cardiothoracic Surgery, University of Vienna, AKH Vienna, Leitstelle 20A, Währinger Gürtel 18-20, 1090 Vienna, Austria.
e-mail: t9204604{at}hotmail.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: The VAC system (vacuum-assisted wound closure) is a noninvasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure by controlled suction to the wound surface. The method was introduced into clinical practice in 1996. Since then, numerous studies proved the effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation.

METHODS: Eleven patients (5 men, 6 women) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting = 5, aortic valve replacement = 5, ascending aortic replacement = 1) were fitted with the VAC system by the time of initial surgical debridement.

RESULTS: Complete healing was achieved in all patients. The VAC system was removed after a mean of 9.3 days (range 4 to 15 days), when systemic signs of infection resolved and quantitative cultures were negative. In 6 patients (54.5%), the VAC system was used as a bridge to reconstructive surgery with a pectoralis muscle flap, and in the remaining 5 patients (45.5%), primary wound closure could be achieved. Intensive care unit stay ranged from 1 to 4 days (median 1 day). Duration of hospital stay varied from 13 to 45 days (median 30 days). In-hospital mortality was 0%, and 30-day survival was 100%.

CONCLUSIONS: The VAC system can be considered as an effective and safe adjunct to conventional and established treatment modalities for the therapy of sternal wound infections after cardiac surgery.

	Introduction

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Since the introduction of median sternotomy by Julian in 1956, sternal wound infections have been a notable and potentially life-threatening complication after open heart surgery, with a reported incidence between 1% and 5%. Despite improvements in antibiotic treatment and techniques of wound care, a 10% to 20% mortality rate as well as substantial morbidity remained constant over the time [1–3].

The treatment of such infections has evolved over the past decades from closed mediastinal antibiotic irrigation, by Mandelbaum and Schumaker in 1963 [4], to the primary use of pectoralis muscle flaps in 1980, by Jurkiewicz and associates [5]. Today, established treatment protocols include aggressive surgical debridement, delayed closure, and plastic reconstruction with muscle and omental flaps, depending on the severity of infection. However, despite substantial advancements, mortality rate remains high and deep sternal wound infection is associated with a prolonged hospital stay, as well as with an increase of cost, particularly when primary therapy has failed [6–10].

The vacuum-assisted closure (VAC) system was first introduced by Argenta and Morykwas in 1997 for the treatment of pressure ulcers and other chronic wounds [11, 12]. Since then, the applications for the VAC system steadily increased over time. The principle of this device is based on a uniform negative pressure applied to the wound, resulting in arteriolar dilatation and thus promoting granulation tissue proliferation [13–18].

We report here about our experience with the VAC system (KCI Inc., San Antonio, TX) as an adjunct in the treatment of sternal wound infections after cardiac surgery.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patients
Eleven patients (5 men [45.5%], 6 women [54.5%]) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting [CABG] = 5 [45.5%], aortic valve replacement [AVR] = 5 [45.5%], ascending aortic replacement = 1 [9.1%]) were fitted with the VAC system by the time of initial surgical debridement.

In patients undergoing CABG, the left internal thoracic artery and the greater saphenous vein were us as bypass grafts. No bilateral internal thoracic artery was used. Patient demographics are shown in Table 1. Duration of the procedure ranged from 3 to 6 hours, with a mean of 4.1 hours. By the time of initial diagnosis, bacteriological cultures of wound secretions and sensibility tests were routinely taken from all patients. Infection was considered to be present if purulent or serous exudation from the sternal wound was observed, together with further signs of infection, such as sternal pain, instability, rubor of wound margins, wound dehiscence, and elevated inflammation parameters, after other causes of infectious origin were excluded. Time between primary cardiac surgery and clinical manifestation of infection varied from 5 to 19 days, with an average of 9.1 days. At this time, 3 patients (27.3%) have been discharged and readmitted after they developed fever and purulent exudate from their sternal wound.

The wound site is then covered with an adhesive drape, therefore converting an open wound into a controlled closed wound. The evacuation tube is connected to a canister where the effluent wound fluid is collected, and the latter is connected to the adjustable vacuum pump, which can generate a negative pressure between 25 and 200 mm Hg.

Methods
All patients underwent surgical debridement under aseptic conditions in the operating theater once sternal infection was confirmed. After reopening of the wound and removal of sternal wires, the mediastinum was carefully evaluated and inspected, and probes for bacteriological cultures as well as sternal bone biopsies were taken. Then, aggressive debridement with removal of all necrotic tissue and irrigation with dilute povidone-iodine solution and H₂O₂ was done. Thereafter, two medium VAC sponges were cut and fitted into the sternal wound proximally and distally. Care was taken so that the pericard was properly closed to ensure no adherence to the surface of the heart. In case of incomplete pericardial adaption, a single layer of a nonadherent open foam dressing was applied. Both sponges were connected with a Y piece, and continuous suction between 75 and 125 mm Hg (median 100 mm Hg) was installed (Figs 1, 2). Patients could be transferred to the normal ward between 2 and 4 hours after surgery. Sedation and prolonged ventilatory support were not necessary.

View larger version (97K): [in this window] [in a new window]   Fig 1. Two medium sponges were cut and sized so that the entire mediastinal wound cavity was filled. Then, the transparent drape was applied over the foam dressing with a 5- to 7-cm border of intact skin to ensure an airtight seal.

View larger version (152K): [in this window] [in a new window]   Fig 2. The vacuum-assisted wound closure system in situ with 100 mm Hg of suction. We routinely use two medium sponges that are fitted proximal and distal between the sternal parts and connected over a Y piece. Through the use of two sponges, the suction is spread more equally over the wound and the sternal parts are better stabilized.

View larger version (126K): [in this window] [in a new window]   Fig 3. A patient after aortic valve replacement and coronary artery bypass grafting on postoperative day 7 in whom deep sternal infection was detected on postoperative day 5. Shown is the wound situation after the first 72 hours with the vacuum-assisted wound closure system. Necrotic tissue is seen between the sternal parts. First signs of the promotion of granulation tissue proliferation can also be seen, which gives the wound the "beefy red" color.

View larger version (114K): [in this window] [in a new window]   Fig 4. The same patient in Figure 3 on postoperative day 13 and after the third vacuum-assisted wound closure dressing change. The wound is completely oversewn with viable granulation tissue, which gives the wound a paler color, as the amount of collagen has increased. Furthermore, the volume of the wound defect is decreasing. Signs of infection have completely resolved. In this patient, a pectoralis muscle flap closure was subsequently performed.

	Results

Top Abstract Introduction Material and methods Results Comment References

Removal of the VAC system was done after a mean of 9.3 days after surgery (range from 4 to 15 days), when systemic signs of infection had resolved and quantitative cultures became negative. All patients received a prolonged course of culture-dependent intravenous antibiotics (mainly trimethroprim and vancomycin) during VAC treatment and postoperative hospitalization for an average of 10 days (range 7 to 21 days). Antibiotics were discontinued when healing was progressing and inflammation parameters were declining.

Median intensive care unit (ICU) stay of patients treated with pectoralis muscle flap closure without pretreatment with the VAC system was 9.5 days (range 4 to 26 days), whereas patients with VAC treatment had an ICU stay of median 1 day (range 1 to 4 days). In-hospital mortality was 0%, and 30 day survival was 100%. Median hospital stay ranged from 13 to 45 days (median 30 days). Besides two revisions because of bleeding after pectoralis muscle flap reconstruction, no other complications were encountered. Most importantly, there were no VAC device–related complications. Similarly, bleeding from the wound did not occur even when full anticoagulation after prosthetic heart valve replacement was needed.

Bacterial cultures isolated Staphylococcus aureus in 6 patients (54.6%), S. epidermidis in 5 patients (45.5%), methicillin-resistant S. aureus in 2 patients (18.2%), and Enterobacter faecalis in 2 patients (18.2%). More than one specimen of bacteria was present in 3 patients (27.3%).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Since the introduction of the VAC device by Argenta and Morykwas in 1997, the device has become a widely accepted technique in the management of chronic and difficult wounds [11, 12]. The principle of the VAC device consists of placing a dressing sponge made of open-cell polyurethane ether foam into a wound. Embedded in the sponge is a sideported evacuation tube, which is connected to the adjustable vacuum pump.

Before insertion of a VAC system, aggressive surgical debridement in order to remove all necrotic tissue is mandatory to achieve acceptable results. Necrotic tissue delays wound healing and increases the likelihood of bacterial colonization of the wound [2]. The treatment options available at the time of initial debridement depend markedly on the macroscopic aspect, depth, and severity of infection. Francel and Kouchoukos have described their personal experience of therapy options for poststernotomy infections in 151 patients over 6 years in a recent publication [3]. However, the VAC system may offer several advantages as compared with the traditional treatment modalities described [11–18]. The uniform negative pressure applied to the wound leads to arteriolar dilatation and thus increases microcirculation, thereby optimizing wound environment. By continuous suction, fluid excess and edema are decreased, thereby reducing bacterial colonization. These positive effects on the wound promote granulation, tissue proliferation, and accelerated wound healing. Therefore, definitive surgical repair, such as primary closure or plastic reconstructive surgery with muscle flaps, can be accomplished safely. Furthermore, a shorter length of time between primary debridement and delayed muscle flap closure decreases the chance of complications and reduces in-hospital stay and costs. This may lead to a reduction of the tremendous impact of healthcare costs caused by deep sternal wound infections, as this is reported to be the most expensive complication after coronary bypass surgery, with a threefold rise in overall costs [1].

Importantly, we observed a significantly shorter ICU stay after muscle flap closure for patients having been treated with the VAC system as compared with patients without VAC system pretreatment. The reason for this might be associated with the better overall condition and the improved wound situation, with a consecutive reduction in bacterial colonization of patients pretreated with the VAC system before definitive surgery. Therefore, the risk of sepsis due to swept bacteria into the circulation is markedly diminished.

Another important factor is the stabilization of the two sternal parts by the vacuum sponge. This reduces shear forces between the beating heart and the sternal edges, and acts as a preventive strategy against the rare, but fatal complication of right ventricular rupture. The firmness of the vacuum sponge acts as a sternal stabilizer, thereby avoiding postoperative intubation and sedation, and furthermore, facilitating early postoperative mobilization and ambulation with the VAC system in place. It is recommended from the manufacturer to use 125 mm Hg suction, as this high pressure stabilizes the sternal parts against shear forces and yields the best results. If the patient does not tolerate this high-pressure therapy, we begin with 75 mm Hg and titrate up to 125 mm Hg the following 24 to 36 hours in conjunction with adequate analgesic therapy consisting of nonsteroidal antirheumatics and opiates.

In accordance with others, muscle flap closure is preferred to omentoplasty, thereby preventing the patient from additional morbidity, which may be encountered by laparotomy and opening of the peritoneal cavity. We favor the pectoralis major muscle flap because of its excellent blood supply furnished by the thoracoacromial arteries and its independency from the internal thoracic arteries as the procedure of first choice, and the rectus abdominis muscle flap as second preference in order to avoid the risk of epigastric herniation after rectus abdominis muscle flap repair [8, 9].

Some potential limitations are worth mentioning. Our study was done with a small patient cohort. We could not find a relation between the incidence of deep sternal wound infection and the commonly reported risk factors. These results are in accordance with a previously published paper by Borer and associates, where only inadequate practices in disinfection, traffic, hand washing, and surgical attire of the nonsterile operating theater personnel, such as anesthesiologists and pump technicians, showed an impact on deep sternal infection rate [20].

In conclusion, we suggest that the VAC system is a valuable and effective adjunct to conventional and established treatment modalities in the management of patients with sustained sternal wound infection after cardiac surgery.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fleck, T. M. Articles by Grabenwoger, M. Search for Related Content PubMed PubMed Citation Articles by Fleck, T. M. Articles by Grabenwoger, M. Related Collections Cardiac - other