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Ann Thorac Surg 2005;80:2205-2212
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Vacuum-Assisted Wound Closure of Deep Sternal Infections in High-Risk Patients After Cardiac Surgery

Kyle Northcote Cowan, MD, PhD, Laura Teague, RN, MN, Sammy C. Sue, BS, James L. Mahoney, MD *

Division of Plastic Surgery, St. Michael's Hospital, and the Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Accepted for publication April 4, 2005.

* Address correspondence to Dr Mahoney, Division of Plastic Surgery, St. Michael's Hospital, Room 4-080, 30 Bond St, Toronto, ON M5B 1W8, Canada (Email: james.mahoney{at}utoronto.ca).


This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org.discuss

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Sternal wound infections are a serious complication arising from cardiac surgery. Recently, the general application of negative pressure to wounds by vacuum-assisted closure (VAC) therapy has shown enhanced granulation and wound contraction. Here we examine the effect of VAC on sternal wounds.

METHODS: We collected and statistically analyzed quantitative VAC performance data and outcomes with a retrospective review on a consecutive cohort of 22 patients treated with VAC for post–cardiac surgery wound complications.

RESULTS: Sternal wound infections became evident on average at 21.0 days after surgery, associated with dehiscence (82%), sternal instability (59%), fluid collection by computed tomography (73%), and osteomyelitis (41%). Cultures most commonly identified Staphylococcus aureus (50%). Prompt irrigation and debridement were performed on all patients, and VAC therapy was applied at approximately 7.3 days after diagnosis. Vacuum-assisted closure induced granulation of 71% of the sternal wound area by 7 days, with a daily drainage of approximately 84 mL. By 14 days, there was a 54% reduction in wound size, and patients were discharged after approximately 19.5 days and placed on home therapy. Vacuum-assisted closure was discontinued at approximately 36.7 days with an average reduction in sternal wound size of 80%. Extensive secondary surgical closure, requiring muscle flaps, was avoided in 64% of patients, whereas 28% of patients required no surgical reconstruction for wound closure. No complications were related to VAC use.

CONCLUSIONS: In contrast to our earlier studies, adjunctive VAC therapy markedly reduced required surgical interventions, reoperation for persistent infections, and the hospitalization period. Thus, VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after medial sternotomy.

Since the first description of medial sternotomy for cardiac surgery by Julian in 1957 [1], life-threatening sternal wound infections have been reported as a significant postoperative complication [2]. Consequently, treatments for mediastinitis have been explored and have evolved with the advent of improved antibiotics, techniques in wound care, and surgical wound closure. Indeed, advanced reconstructive techniques using muscle flaps have become the mainstay of surgical treatment [3]. While these advances have had an impact on reducing mortality, significant rates are still reported, as well as a substantial morbidity associated with these infections [4].

In 1996 and 1997, Argenta and Morykwas [5] and Fleischmann and coworkers [6] individually reported the use of negative pressure to enhance wound granulation and closure in a technique known as vacuum-assisted closure (VAC). Since then, VAC therapy has been applied to various types of wounds and, more recently, to infected sternal wounds [7, 8]. While these recent studies have begun to track the efficacy of VAC therapy for the treatment of poststernotomy mediastinitis, more quantitative studies assessing VAC performance and documenting progressive wound changes under VAC are required. Here we quantitatively describe the effect of VAC therapy on 22 patients with sternal wound infections at our institution.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
The present study is a retrospective chart review (2000 to 2002) of all patients at our institution who received VAC (KCI, San Antonio, Texas) therapy for wound closure after developing post–cardiac surgery sternal wound infections. All wounds were deep sternal wounds with or without bony involvement. Data on patient demographics, previous surgery, sternal wound characteristics, overall treatment, wound measurements, VAC settings, and patient outcomes were collected. Patients were categorized based on the nature of their mediastinal wound using the El Oakley classification of postoperative mediastinitis [2], as well as the presence of comorbid factors reported to adversely affect wound healing, and the EuroSCORE (European System for Cardiac Operative Risk Evaluation) [9], assessing risk of early mortality in cardiac surgical candidates. Information was retrieved with hospital medical ethics approval from the clinical database and medical records, analyzed, and is presented as percent or mean ± SD.

In cardiac patients referred with sternal wound problems, our management began with confirmation of sternal wound infection. This involved assessing the wound for clinical signs of infection and sternal instability. Culture of soft tissue, and bone where applicable, were obtained. While copious drainage, sternal instability, wound dehiscence, and deep substernal extension of the wound were considered clinically indicative of sternal bone involvement, computed tomography scanning was utilized to further delineate this process as well as to evaluate for the presence of either pulmonary or pericardial fluid collections. Patients were then placed on systemic antibiotics and sternal wounds were irrigated and debrided. Given the stability of this patient population and dependent upon the characteristics of the sternal wounds, wounds were most often debrided at the bedside. Once the necrotic tissue was removed, VAC dressing could be applied and suction initiated. Over the course of treatment, wounds with persistent areas of necrosis were further debrided and the VAC reapplied. Some patients, however, were deemed not to be candidates for VAC therapy on the basis of initial presentation involving copious purulent drainage or associated sepsis, or both. In these patients, more extensive urgent surgical debridement and often initial sternectomy was required, with closure obtained using standard surgical techniques.

Application of VAC involved tailoring porous polyurethane foam to fill the wound. Within the foam was embedded a noncollapsible evacuation tube to which a negative pressure vacuum was applied. Transparent adhesive drape covered the wound and foam, and pressure was initiated at –50 mm Hg, subsequently increased, and maintained either continuously or with intermittent cycling. The VAC dressings were changed every 2 days. Wound assessment and care was consistently managed by our St. Michael's Hospital multidisciplinary wound care team, including plastic surgeons, wound care nurse practitioners, and rehabilitation therapists.

Specifics of VAC treatment were quantitatively characterized in terms of pressure applied, duration of therapy, and changes in wound size, drainage, and degree of tissue granulation. Volumetric wound measurements were performed using a standard ruler and granulation was estimated as a percent of the surface area of the wound. Drainage was assessed as the fluid extracted from the wound by VAC as measured in the disposable VAC graduated collection container. Once initiated, VAC therapy was continued until granulation to skin level was complete or until the wound ceased to further contract. Sternal wounds were then, dependent upon their size, either allowed to close by secondary intention, or closed surgically, either directly or with regional flaps, again on the basis of wound size as well as the degree of granulation and viability of the VAC pretreated wound bed.

Differences between risk groups and changes in wound size are expressed as mean ± SD and statistical significance was determined using one-way analysis of variance followed by Fisher's least significant difference test of multiple comparisons to establish individual group differences. The limitations of the present study are in keeping with and include those of any retrospective review. During the course of this research, no funding was accepted from KCI or any other source.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Twenty-two patients with sternal wound infections were referred from cardiac surgery to our care from 2000 to 2002. The demographics of this population are summarized in Table 1, which shows the presence of numerous comorbid conditions affecting wound healing were present. An average of 2.41 ± 1.56 comorbid conditions was present per patient. The application of the EuroSCORE early cardiac mortality risk classification yielded an overall score of 9.41 ± 4.3. As previously reported, a score of this nature indicates a high-risk patient population [9]. Details of the various cardiac operations are also itemized in Table 1, with the most common operation being coronary artery bypass grafting (59%). Most cases were elective (86%), and before our consultation, chest reopening frequently occurred (54%).


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  		Table 1. Demographic and Cardiac Surgery Data for the 22 Study Patients
 
Onset of mediastinitis was heralded by the signs and features graphically displayed in Figure 1a. These features included, most profoundly, pain in 100%, discharge in 95%, and wound dehiscence in 82%. Erythema was present in 54% and sternal instability to palpation was detected in 59%. In addition, computed tomography scan detected fluid collections in 73% of patients. Sternal cultures reported osteomyelitis in 41%. Mediastinal soft tissue cultures grew multiple bacterium, most commonly, Staphylococcus aureus (50%) and coagulase negative Staphylococcus organisms (45%), but also Pseudomonas (23%), Klebsiella (9%), and Escherichia faecalis organisms (4%; graphically displayed in Fig 1b).



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  		Fig 1. Evidence of and bacteria colonizing sternal wound infections. (a) Graphical summary of the frequency with which various signs, symptoms, imaging of fluid collections, and biopsy indicative of osteomyelitis were reported in patients with mediastinitis. (b) Frequency of colonization of sternal wounds by various bacterium, and summarized graphically. (Bars = n of 22, and are not mutually exclusive; Coag Neg Staph. = coagulase negative Staphylococcus; CT = computed tomography; E. faecalis = Escherichia faecalis; S. aureus = Staphylococcus aureus.)

 
Diagnosis of mediastinitis (with deep culture) was confirmed on average at 21.0 ± 6.8 days after surgery (Table 2). Assignment of a grade using the El Oakley mediastinitis classification averaged 3B to 4A (range, 3A– to 5) indicating mediastinal infections that are both advanced and high risk (Table 1) [2]. Vacuum-assisted closure was subsequently initiated after irrigation and debridement of the wound on average at 7.3 ± 2.2 days after diagnosis (28 days after surgery). The delay between diagnosis of sternal infection and application of VAC therapy was primarily related to the availability of a limited supply of VAC equipment as well as to availability of wound team members whom are required to apply and monitor ongoing VAC therapy amongst their many other duties. Therefore, we would like to emphasize that we welcome earlier involvement of our service, at a time when sternal infection is merely suspect, as this may reduce the time lag between consultation and application of VAC and potentially translate to a reduction in treatment course required and morbidity. Treatments used in conjunction with VAC therapy are summarized in Table 3, with all patients receiving prompt irrigation, local wound debridement, and systemic antibiotics. Vacuum-assisted closure initiation pressure was -50 mm Hg and, progressively increased, with an overall mean pressure employed of -88.6 mm Hg (final pressures ranging from -75 to -125 mm Hg; Table 2). A typical sternal wound before VAC after debridement is shown in Figure 2a. The effect of 2 weeks of VAC therapy on the same patient is illustrated in Figure 2b, showing the presence of significant granulation tissue and a marked reduction in wound size. Figure 2c shows, in the same patient, the sternal wound at the completion of VAC therapy with a minimal open wound and a healthy bed of granulation tissue.


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  		Table 2. Quantitative Analysis of Vacuum-Assisted Wound Closure (VAC) Therapy (n = 22)
 

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  		Table 3. Vacuum-Assisted Wound Closure (VAC) Outcomes and Adjunctive Therapies (n = 22)
 


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  		Fig 2. Changes in sternal wound size with the application of vacuum-assisted closure (VAC) therapy. (a–c) Photographs of a representative sternal wound after debridement, but (a) before VAC application, (b) after 2 weeks of VAC therapy, and (c) at completion of VAC therapy. (d) Graphical summary of mean changes in wound size in the 22 study patients. Bars represent mean ± SD with n = 22. *p < 0.05 compared with wound size before VAC application.

 
To quantify the effects of VAC therapy on wound closure, sequential measurements of sternal wound size were made on the 22 patients and showed progressive, rapid, improvements over the course of VAC therapy, as illustrated in Figure 2d. Reduction in wound size averaged 54% ± 23% by day 14, with a final reduction in wound size of 80% ± 21% occurring at the termination of VAC therapy (p < 0.05; Table 2). Indeed, by day 7, on average 71% ± 14.4% of the sternal wound area showed the presence of granulation tissue. Average wound drainage over the first 14 days was approximately 84 ± 4.7 mL per day. After initiation of VAC therapy, patients were on average discharged home at 19.5 ± 7.3 days, and VAC treatment was discontinued on average after 36.7 ± 17.6 days.

The use of VAC was associated with a reduced need for secondary surgical intervention using regional flap coverage for wound closure in 14 patients (64%; Table 3). Of these, 8 patients (36%) received direct surgical wound closure (tertiary intention), and 6 patients (28%), were allowed to completely granulate in, closing by secondary intention. The remaining 8 patients (36%) in whom dramatic improvements on VAC were not being realized, received additional debridement and surgical reconstruction using a regional flap, most commonly pectoralis major, with or without sternectomy. The result of VAC therapy, summarized in Table 3, showed survival at 95% (21 of 22 patients, measured as more than 6 months of infection-free health). The sole death was due to cardiac dysrhythmia and thus was unrelated to VAC therapy. No complications, such as chronic or persistent infections or surrounding tissue damage, were associated with VAC. In addition, in consultation with our cardiac surgical colleagues, no marked qualitative differences in coronary artery bypass graft patency were noted.

Next, to address the impact of wound healing comorbidities (Table 1) on VAC performance and wound healing, we subdivided our patient population into higher and lower risk groups based on the number of associated wound healing comorbidities. The higher risk group consisted of patients with a greater number of comorbidities (2.8 ± 1.5 on average, n = 12), whereas the lower risk group consisted of patients with a fewer number of comorbidities (1.1 ± 1.6 on average, n = 10; p < 0.05), as summarized in Table 4. In the population whose risk was higher, an increased wound size was evident (206 ± 132 cm3) compared with patients with a lower risk (137 ± 54 cm3; p < 0.05), together with a significant increase in sternal instability (83.3%, versus 30.0% in the lower risk group; p < 0.05; Table 4). The higher risk population also exhibited a protracted healing course with a significant reduction in granulation tissue evident after 1 week (63% ± 12%, versus 80% ± 15% in the lower risk group; p < 0.05) and exhibited a trend toward a decreased reduction in wound size at 2 weeks of VAC (52% ± 22%, versus 57% ± 24% in the lower risk group). This population, as a result, required a longer duration of VAC therapy, 57 ± 30 days compared with 25 ± 8 in the lower risk group, and represented all patients requiring either sternectomies (62%) or secondary surgical closure with regional flaps (67%). In particular, only 17% of wounds in the high-risk population closed by secondary intention alone. By contrast, none of the patients in the lower risk group required either sternectomy or regional flap closure. Wound closure in all lower risk patients either required only direct surgical closure (60%) or occurred by secondary intention alone (40%). Interestingly, as sternal instability was the only physical sign markedly elevated in the higher risk population, its presence at diagnosis is suggestive of the future need for more aggressive surgical intervention. Specifically, the presence of sternal instability at diagnosis was associated with a 2.1-fold increase in the subsequent need for regional flap coverage for definitive wound closure. Despite these marked differences, the outcome was the same in both populations (when normalized for the 1 death unrelated to VAC), in which infection-free survival was realized. Consistent with this, EuroSCORE calculations [9], predicting early cardiac surgical mortality, for both groups showed no significant difference.


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  		Table 4. Comparison Vacuum-Assisted Wound Closure (VAC) in Higher Versus Lower Risk Patient Populations
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Taken together, the management of deep sternal wound infections at our institution, as summarized in Figure 3, begins with the initial presentation of a potential wound infection, most commonly involving sternal drainage together with other early signs of infection. A referral to plastic surgery and the wound care team is most appropriate at this time and results in a comprehensive wound assessment. If no infection is identified, wound drainage and dehiscence are dealt with by allowing the wound to heal by secondary closure with or without VAC application for large wounds. However, if the presence of mediastinitis is established, irrigation and debridement of the wound are performed together with initiation of antibiotic therapy. Once adequately debrided, VAC therapy is applied and followed with frequent wound care team assessment. If, however, copious purulent drainage from the wound is present or the patient is established to be septic, more aggressive and urgent surgical debridement and reconstruction would then be performed, often necessitating sternectomy for osteomyelitis and muscle flap coverage to attain primary closure. For patients receiving VAC therapy, wound improvement was noted as the increasing presence of healthy granulation tissue and overall wound contracture in the absence of tissue necrosis. In these patients, VAC therapy was continued until granulation to skin level (secondary closure) was complete. Alternatively, if wound improvement arrested under VAC, indicated by no further development of granulation tissue or wound contracture, wounds were then either allowed to gradually close by granulation (secondary closure) or selected for surgical closure (tertiary closure) with or without muscle flaps. These decisions were based on wound size as well as the degree of granulation tissue present and the viability of the VAC pretreated wound bed. In this way, VAC also assisted in the management of sternal wound infections through the identification of patients who, with continuous wound improvements under VAC, did not require more extensive surgery.



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  		Fig 3. Management algorithm for deep sternal wound infections. The schematic details, in a stepwise fashion, the management of deep sternal wound infections at our institution. This process flows from initial presentation through assessment and establishing the presence of mediastinitis to treatment options, including standard therapies and vacuum-assisted closure (VAC) application. This process also highlights the patient population in whom we did not use VAC as well as the process by which we monitored improvements under VAC therapy and the resultant treatment options based upon those assessments. (CT = computed tomography.)

 
In the present study, we have addressed VAC therapy in patients whose demographic profile suggests a higher risk population. Given that these patients are clearly poor surgical candidates, establishing a nonsurgical treatment modality is of particular benefit. Interestingly, despite these higher risk patient attributes, VAC was successfully applied. To further provide clinically applicable benchmarks, we have explored for the first time the impact of wound healing comorbidities on VAC therapy. Thus, upon presentation, realistic goals for VAC therapy may now be estimated. Specifically, patients with a greater number of comorbid factors can be expected to have a markedly protracted course of therapy, be more likely to require regional flaps for definitive closure, and yet have an equally favorable final outcome.

The present study provides marked contrast to earlier work by our group in this patient population. Bray and colleagues [10] previously examined the efficacy of conventional mediastinitis treatment before the introduction of VAC therapy at our institution. In their work, an increased need for surgical interventions (specifically regional flap coverage) was observed. Reoperations for persistent sternal infections were also considerably more frequent and the duration of hospitalization markedly prolonged.

The differences realized with VAC therapy, when compared with earlier therapies, are likely reconcilable in the light of the documented functions of VAC. In particular, Argenta and Morykwas [5] and Morykwas and coworkers [11] have shown that the application of subatmospheric pressure to wounds promotes the formation of granulation tissue. Moreover, they have shown that VAC also reduces excess fluid accumulation and edema, that may contain toxic by-products of infection and prolonged inflammation. Tissue bacterial counts in infected wounds were also reduced by 21% with VAC compared with controls [11]. All of these factors would normally impede wound healing. In addition, this process occurs while maintaining a moist environment, permissive to the promotion of cellular migration, unlike the dehydrated state seen with the occlusive dressings, previously used.

Vacuum-assisted closure may also provide a pressure-mediated wound contraction and stabilization that facilitates expedient closure. The provision of a collapsed foam filler that removes devoid space and connects wound edges may function as a provisional scaffolding giving support to unstable sternal wounds. Even a modest reduction in instability in such wounds, preventing traction and shear forces, particularly associated with coughing, chest flail, or deep respiration, may yet be another way in which VAC therapy enhances wound closure. Thus, the provision of a more physiologically optimal environment, through the alleviation of these common impediments to successful wound healing, likely enables the improved outcomes documented in the present study.

The benefits of VAC therapy are likely not solely physiologic, but may also be efficacious from a cost perspective. Indeed, the treatment costs associated with mediastinal infections are considerable, given the surgical interventions used, the frequency of wound care provided, and the protracted duration of hospitalization required [12]. In addition, while earlier wound care protocols required dressings to be changed twice a day with early changes often requiring analgesia, VAC foam dressing changes are adequately performed only every 2 days and, with the moist environment maintained, rarely require any form of analgesia. This more flexible schedule, combined with the development of portable VAC systems, has enabled VAC use as home therapy (with registered nurses doing dressing changes every 2 days), alleviating the extensive costs of hospitalization and easing the demand on inpatient beds. In addition, as described previously in this study, the frequency of more costly surgical interventions is greatly reduced. Together, these features make the purchase and institution of VAC therapy a more feasible and prudent prospect and, thus, warrant further investigation.

Recently, Domkowski and associates [8] have shown the use of VAC therapy with a 4% mortality rate in which 45% of patients required flap closure. Also, Luckraz and coworkers [13] have reported a 30% use of flaps with an overall mortality rate of 31%. By contrast, our study describes both low mortality (4%) and low regional flap usage (36%). Our study also illustrates the impact of VAC therapy at the same institution and in the same patient population with comparisons to our previous studies, and quantitatively characterizes the clinical parameters of VAC, highlighting differences between higher and lower risk populations. With a better understanding of VAC therapy and its application, we will be able to provide our patients with realistic expectations in treatment and alternatives to more radical surgical intervention that may be inappropriate under defined circumstances. That will ultimately translate into improved patient satisfaction with treatment as well as improved clinical outcomes achieved.

Taken together, these data suggest that, with standard adjunctive treatment, VAC therapy for postoperative mediastinitis is an efficacious method by which to facilitate a rapid reduction in wound size, and enhanced wound granulation allowing early wound closure with a reduced dependence upon regional flap usage for closure. This approach is also indicated in higher risk patients, providing similar, however protracted, results. Furthermore, this rapid wound closure may translate into fewer long-term complications and reduced treatment costs, which are presently the topic of future investigation.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors would like to acknowledge the dedicated work of the members of the St. Michael's Hospital multidisciplinary wound care team and also Paul Doherty for his critical review of the manuscript and Sammy C. Sue for editing revisions into the manuscript.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. The medial sternal incision in intracardiac surgery with extracorporeal circulationa general evaluation of its use in heart surgery. Surgery 1957;42:753-761.[Medline]
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  3. Francel TJ, Kouchoukos NT. A rational approach to wound difficulties after sternotomyreconstruction and long-term results. Ann Thorac Surg 2001;72:1419-1429.[Abstract/Free Full Text]
  4. Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH. Mediastinitis after coronary artery bypass graft surgeryrisk factors and long-term survival. Circulation 1995;92:2245-2251.[Abstract/Free Full Text]
  5. Argenta LC, Morykwas MJ. Vacuum assisted closure. A new method for wound control and treatmentclinical experience. Ann Plast Surg 1997;38:563-577.[Medline]
  6. Fleishmann W, Lang E, Kinzl L. Vacuum-assisted wound closure after dermatofasciotomy of the lower extremity Unfallchirurg 1996;99:283-287.[Medline]
  7. Hersh RE, Jack JM, Dahman MI, Morgan RF, Drake DB. The vacuum-assisted closure device as a bridge to sternal wound closure Ann Plast Surg 2001;46:250-254.[Medline]
  8. Domkowski PW, Smith ML, Gonyon Jr DK, et al. Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis J Thorac Cardiovasc Surg 2003;126:386-390.[Abstract/Free Full Text]
  9. Nasher SAM, Roques F, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE) Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  10. Bray PW, Mahoney JL, Anastakis D, Yao JKY. Sternotomy infectionssternal salvage and the importance of sternal stability. Can J Surg 1996;39:297-301.[Medline]
  11. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation Ann Plast Surg 1997;38:553-562.[Medline]
  12. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complication after isolated coronary bypass graftingearly and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
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