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Ann Thorac Surg 2003;76:2104-2106
© 2003 The Society of Thoracic Surgeons

Case report

New strategy for treatment of MRSA mediastinitis: one-stage procedure for omental transposition and closed irrigation

Nobuaki Hirata, MDa*, Shinichi Hatsuoka, MDa, Akira Amemiya, MDa, Takayoshi Ueno, MDa, Yoshio Kosakai, MDa

a Division of Cardiovascular Surgery, Takarazuka Municipal Hospital, Takarazuka, Hyogo, Japan

Accepted for publication April 23, 2003.

* Address reprint requests to Dr Hirata, Division of Cardiovascular Surgery, Takarazuka Municipal Hospital, 4-5-1, Kohama, Takarazuka, Hyogo 665-0827, Japan
e-mail: hirata{at}xd5.so-net.ne.jp


   Abstract
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 Abstract
Introduction
 Case reports
 Comment
 References
 
Mediastinitis due to methicillin-resistant Staphylococcus aureus is a devastating potential complication of cardiac surgery. We treated 4 patients with this condition using a new technique. First we performed an early radical removal of infected tissue and omental transposition with direct primary closure of the sternum and closed continuous irrigation with saline/vancomycin hydrochloride; that was followed by an administration of intravenous antibiotics. We obtained good clinical results, which are reported herein along with the clinical courses.


   Introduction
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 Abstract
 Introduction
Case reports
 Comment
 References
 
Mediastinitis is a devastating potential complication of cardiac surgery. Although the rate of incidence in patients who have undergone a median sternotomy for cardiac surgery with cardiopulmonary bypass (CPB) ranges from 1% to 2.5%, the associated mortality rate varies from 14% to 47% [1]. Furthermore when the causative pathogen is methicillin-resistant Staphylococcus aureus (MRSA) the mortality risk becomes significantly higher [2]. However effective treatment for mediastinitis including MRSA mediastinitis remains controversial [1, 3, 4].

We treated 4 patients with MRSA mediastinitis using a new technique that utilized both omental transposition and closed continuous irrigation with vancomycin hydrochloride. Herein we report our good clinical results along with the clinical courses.

We reviewed the records of 180 consecutive patients who underwent open heart surgery from November 1, 1998, through August 31, 2001. Of those, 4 patients who had a reexploration because of MRSA mediastinitis were chosen for this study.

A complete debridement of the sternum and mediastinum was performed as soon as mediastinitis was detected. The omentum was flapped and transpositioned over the mediastinum; however the lateral side of the right atrium remained uncovered, the omentum was transpositioned in order to localize the infectious sites to the lateral side of the right atrium, and was followed by closed irrigation. The irrigation device consisted of three irrigation tubes, which were placed in the upper half of the mediastinum, the pericardium, and just to the lateral side of the right atrium. Two other drainage tubes were placed in the upper half of the mediastinum and in the pericardial space. The wash, dripped continuously, was composed of vancomycin (2 g) and chloramphenicol (2 g) with 1,000 mL of physiologic saline per day.


   Case reports
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 Abstract
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 Case reports
Comment
 References
 
Patient 1
A 73-year-old man underwent elective coronary artery bypass graft (CABG) surgery with two bypass grafts using the left internal thoracic artery (ITA) and a saphenous vein graft (SVG). Cardiopulmonary bypass time was 84 minutes and operative time was 255 minutes. Although he was not an MRSA carrier, MRSA mediastinitis was found 10 days after the operation. Thus a rethoracotomy was performed with debridement and omental transposition. After 4 days another rethoracotomy was performed owing to regained mediastinitis and continuous closed irrigation was started. The postoperative course is shown in Table 1.


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  		Table 1. Postoperative Courses

 
Patient 2
A 59-year-old woman underwent an emergent ascending aorta and total arch replacement because of dissecting aneurysm. Cardiopulmonary bypass time was 161 minutes and operation time was 440 minutes. Although it was not ascertained if she was an MRSA carrier, MRSA mediastinitis was found 9 days after surgery and we performed a rethoracotomy with debridement and omental transposition, as with patient 1. After 6 days another rethoracotomy was performed and closed irrigation was started. The postoperative course is shown in Table 1.

Patient 3
A 78-year-old woman underwent emergent CABG surgery with two bypass grafts using the left ITA and SVG. Cardiopulmonary bypass time was 91 minutes and operation time was 210 minutes. Although it was not ascertained if she was an MRSA carrier, MRSA mediastinitis was found 8 days after surgery. Based on our experiences with the previous patients, omental transposition and closed irrigation of the mediastinum were started simultaneously. The postoperative course is shown in Table 1.

Patient 4
A 75-year-old man underwent elective CABG surgery with two bypass grafts using left ITA and SVG. Cardiopulmonary bypass time was 85 minutes and operation time was 520 minutes. He was not an MRSA carrier but MRSA mediastinitis was found 7 days after the operation. We performed the same proceduree as for patient 3. He underwent an omental flap procedure and closed irrigation of the mediastinum concurrently. The postoperative course is shown in Table 1.


   Comment
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 Abstract
 Introduction
 Case reports
 Comment
References
 
Our strategy for these MRSA mediastinitis cases was to localize the infection site absolutely and irrigate with vancomycin. The first 2 cases underwent omental transposition, followed by closed irrigation approximately 1 week later. In those, we intended to localize the infection site in the lateral side of the right atrium before the second procedure for closed irrigation. Thus we placed one of the three irrigation tubes in the localized space and the other two irrigation tubes and the two thick suction drains were brought in around the heart and just beneath the sternum. In the latter 2 patients, we performed omental transposition and closed irrigation concurrently according to our experiences with the first 2 cases.

A recent report described a primary closure method using a new irrigation-suction system that provided good results [5, 6]. Closed irrigation techniques are not without complication however, as some have noted that when the foam is removed there is a risk for bleeding in the wound because of some granulation growth [7]. To avoid this potential problem we positioned the omental flap over the mediastinum except for the lateral side of the right atrium and we did not experience any bleeding from the wound even when the foam was removed.

All of the patients described here began to eat and walk shortly after starting closed continuous irrigation, demonstrating that our strategy enabled early postoperative rehabilitation, which we consider to be an important advantage. We recommend this combination method of primary closure of the sternum after complete debridement of the infected tissue and omental transposition, accompanied by absolute closed continuous irrigation with vancomycin, for effective treatment of poststernotomy mediastinitis.


   References
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 Abstract
 Introduction
 Case reports
 Comment
 References
 

  1. El Oakley R.M., Wright J.E. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61:1030-1036.[Abstract/Free Full Text]
  2. Sheagren J.R. Staphylococcus aureus: the persistent pathogen. N Engl J Med 1984;310:1473.
  3. Lee A.B., Schimert G., Shatkin S. Total excision of the sternum and thoracic pedicle transposition of the greater omentum: useful strategies in managing severe mediastinal infection following open heart surgery. Surgery 1976;80:43-46.
  4. Gottlieb L.J., Pielet R.W., Krieger L.M., Smith D.J., Deeb G.M. Rigid internal fixation of the sternum in postoperative mediastinitis. Arch Surg 1994;129:489-493.[Abstract/Free Full Text]
  5. Molina J.E. Primary closure for infected dehiscence of the sternum. Ann Thorac Surg 1993;55:459-463.[Abstract]
  6. Catarino P.A., Chamberlain M.H., Wright N.C., et al. High-pressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis. Ann Thorac Surg 2000;70:1891-1895.[Abstract/Free Full Text]
  7. Levi N., Olsen P.S. Primary closure of deep sternal wound infection following open heart surgery: a safe operation?. J Cardiovasc Surg 2000;41:241-245.[Medline]



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This Article
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