Ann Thorac Surg 2005;80:2212
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Eddie L. Hoover, MD
Department of Surgery, Buffalo VAMC, 3495 Bailey Ave, Buffalo, NY14215
(Email: eddie.hoover{at}med.va.gov).
These authors [1] report their experience with 22 patients who had deep mediastinal wound infections develop after cardiac surgery in which a vacuum-assisted closure (VAC) system was utilized to facilitate wound healing. Patients with copious drainage or sepsis were excluded. Sixty percent underwent revascularization procedures, 36% had valve replacement, and 4.5% had aortic reconstruction. The presence of mediastinitis has serious implications for possible graft occlusion, endocarditis of prosthetic valves, and contamination of grafts used in reconstruction. Clearly, early and efficacious wound healing is necessary to mitigate these complications. Patients were classified using the Oakley designation of mediastinitis, co-morbid factors and the EuroSCORE system, which does not use serum albumin as one of it indices, resulting in a high-risk and low-risk grouping. The diagnosis was made using standard indicators of pain, wound discharge, dehiscence, and fluid collections on computed tomographic scans. Osteomyelitis was present in 41%, and 5 of 22 patients required sternectomy. The major organisms were Staphylococcus aureus in 50% followed by coagulase negative Staphylococcus in 45%. The diagnosis was made on average at 21 ± 6.8 days after surgery, which seems a bit late. They cited some learning curve issues early on, which I suspect will shorten the time to intervention in the future. The authors make the important distinction between wounds that are draining but not infected, as to which ones will require VAC therapy. The VAC system was placed by an experienced nurse and pressure was gradually increased to –75 to –125 mm Hg with continuous or intermittent cycling. Vacuum-assisted closure therapy was continued either until the granulation layer reached skin level or until wound contraction ceased.
After VAC therapy, 8 patients had direct wound closure, 6 were healed by secondary intention, and the remaining 8 underwent regional flap closure. As expected the high-risk group required longer periods of VAC and included all patients requiring sternectomy and muscle flap closure. We have used this modality in the treatment of 5 patients with exposed vascular grafts with satisfactory wound healing in all cases. We also used it successfully in a patient who had mediastinitis develop after removal of a thymoma. Of note, his wound healed with only a layer of squamous epithelium covering the sternum, which proved to be very friable and painful, and he was reconstructed using regional flap coverage. Therefore we support the use of this modality in the treatment of mediastinitis and agree with their recommendation of early consultation with plastic surgeons and the wound-care team to prevent diagnosis and treatment delays due to the surgeon's denial. They postulate a scientific basis for improved wound healing with VAC, but this will require more scientific investigation with hard data. They present a very useful algorithm, which should be within arm's reach of every surgeon doing median sternotomy for any reason.
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- Cowan KN, Teague L, Sue SC, Mahoney JL. Vacuum-assisted wound closure of deep sternal infections in high-risk patients after cardiac surgery Ann Thorac Surg 2005;80:2205-2212.[Abstract/Free Full Text]
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