Ann Thorac Surg 2009;88:987-989. doi:10.1016/j.athoracsur.2009.01.037
© 2009 The Society of Thoracic Surgeons
Case Reports
Simultaneous Surgery of the Aortic Valve and Sternal Osteomyelitis
Paul P. Urbanski, MDa,*,
Yvonne Lindemann, MDa,
Jörg Babin-Ebell, MDa,
Steffen Fröhner, MDb,
Anno Diegeler, MDa
a Department of Cardiovascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
b Department of Radiology, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
Accepted for publication January 14, 2009.
* Address correspondence to Dr Urbanski, Herz- und Gefaess-Klinik, Salzburger Leite 1, Bad Neustadt, 7616, Germany (Email: p.urbanski{at}kardiochirurg.de).
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Abstract
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A 64-year-old man was referred for aortic valve replacement due to severe stenosis. He also suffered chronic sternal osteomyelitis with skin fistula subsequent to radiation therapy. Both pathologies were approached simultaneously by sternal resection, omental plasty, and valve replacement, which led to favorable primary and mid-term result.
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Introduction
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Treatment of patients with chronic sternal osteomyelitis after radiation is associated with extended resection of all altered tissue, and consequently with subsequent complex surgical reconstruction [1]. Therefore, in patients with additional valvular disease necessitating surgery, the appropriate approach remains unclear. We report a case of chronic sternal osteomyelitis after radiation and severe aortic valve stenosis. The patient was treated simultaneously by complete sternal resection, aortic valve replacement, and transposition of the omentum flap into the mediastinum. We believe that this approach has not been published previously.
In the presented case, a 64-year-old man received radiation therapy for intrathoracic sarcoma 19 years before the surgery at our facility (200vK, 20 mA, 4000 rad). Sixteen years after radiation, a spontaneous fracture of the sternum body occurred leading to skin perforation and consecutive development of a chronic fistula. In this time, he also suffered incremental dyspnea finally resulting in the New York Heart Association functional class III; however, his quality of life was limited, basically by the pain within the sternum and the chronic fistula.
The cardiological examination revealed a calcified aortic valve stenosis with a mean gradient of 38 mm Hg and an orifice area of 0.6cm2 combined with a mild insufficiency. The left ventricular ejection fraction was reduced to 20%. Because of the chronic sternal osteomyelitis with skin fistula, the patient was rejected for surgery by various cardiothoracic surgical units. On presentation at our facility, the laboratory examination results were normal except for an elevated C-reactive protein of 51.5. Streptococcus viridians and Staphylococcus epidermidis could be cultivated from the fistula. The computed tomographic scan showed the fracture of the sternum and nearly complete destruction of the sternum body with multiple sequestrations (Fig 1). For the reasons that are explained in the "Comment" section of this article, we decided on simultaneous surgery.
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Fig 1. Preoperative sagittal reconstruction (left) and axial image (right) of a contrast-enhanced computed tomographic scan showing bone destruction of sternum due to osteomyelitis with pathologic fracture and dislocation.
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The surgery included extensive resection of the skin and soft tissue, as well as complete sternum resection. The mediastinal tissue was not viable and had to be resected down to the aorta within the pericardium. The cardiopulmonary bypass was then established by cannulation of the distal ascending aorta and the right atrium. The aortic valve was replaced using a 23-mm St. Jude Regent valve prosthesis (St. Jude Medical, St. Paul, MN) completed by the endarterectomy of the aortic root and a decalcification of the mitral valve. For closure of the wound, the omentum flap was prepared through an upper midline abdominal incision and transposed into the anterior mediastinum. The pectoralis major was mobilized on both sides together with the skin and used to supplement the omentum and stabilize the wound. In doing so, the skin could be closed primarily; however, two additional pledgeted U-sutures were applied for securing the wound to reduce too strong tension. Antibiotic treatment with combination of three products (cefuroxim, vancomycin, and rifampicin) was continued for 7 days. Primary wound healing occurred; however, the postoperative course was complicated by a respiratory insufficiency that required reintubation and ventilation for 110 hours in total and by an atrioventricular block requiring pacemaker implantation on postoperative day 10. The patient was discharged on postoperative day 28. At the follow-up-time of 12 months after surgery, the patient was in New York Heart Association functional class I and suffered no disorders, particularly no chest pain. The scar after the sternotomy healed without any signs of inflammation (Fig 2). The control computed tomographic scan showed good consolidation after complete resection of the sternum without signs of infection or abscess formation in the anterior mediastinum (Fig 3).
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Fig 2. Patient's photograph at 1 year after surgery showing the postoperative scar without signs of inflammation. Note that the wound closure (including the skin) was performed primarily. The visible net-like alterations of the skin with multiple round areas are the effect of radiation dermatitis that occurred subsequently to the radiation performed 20 years ago.
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Fig 3. Postoperative sagittal reconstruction (left) and axial image (right) of a contrast-enhanced computed tomographic scan shows filling of defect after sternum resection with fatty tissue of omentum flap and complete skin coverage.
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Comment
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In the presented case, several surgical options, either simultaneous or staged, could have been possible. For the staged procedure, alternative approaches to the ascending aorta, such as right-sided intercostal or parasternal incisions, could have been considered [2–5]. These incisions do not require a sternotomy; however, they could demand the ligation of the internal mammary artery, compromising even more of the blood supply in the irradiated area. Moreover, this approach would have been very difficult because of the alteration of the mediastinal tissue and pericardium directly at the front of the ascending aorta. This could have even led to serious iatrogenic injuries during preparation. In addition, valve replacement before the treatment of the sternal osteomyelitis could have increased the risk of prosthetic endocarditis. This and the age of the patient were indeed the reasons why the patient was neither considered for transfemoral or apical valve implantation.
On the other hand, a treatment of the sternal infection prior to aortic valve replacement would have lasted several months and would have aggravated a later approach to the ascending aorta as well, because in chronic infections after radiation, a very extensive resection of all altered tissue is necessary. Moreover, even after complete healing of the wound, there would again have been a risk of infection during the second surgical stage for valve replacement.
Because the patient was in severe distress from the aortic valve stenosis, as well from his chronic infection, we chose a simultaneous procedure. This approach offered not only simultaneous curing of two serious pathologies, but also an extensive resection of all post-radiation-altered tissue, which is a prerequisite for optimal surgical healing.
We believe that in cases of sternal infection and concomitant aortic valve pathologies requiring surgery, a simultaneous approach with valve repair or replacement combined with radical resection of all infectious tissue and primary wound closure using omental plasty is a safe and efficient surgical option.
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Acknowledgments
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The authors would like to thank Mrs Melissa Lindner, Mrs Alexandra Metz, and Mrs Bianca Müller for preparing this article.
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References
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- Beahm EK, Chang DW. Chest wall reconstruction and advanced disease Semin Plast Surg 2004;18:117-129.
- Benetti FJ, Mariani MA, Rizzardi JL, Benetti I. Minimally invasive aortic valve replacement J Thorac Cardiovasc Surg 1997;113:806-807.[Free Full Text]
- Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
- Minale C, Reifschneider HJ, Schmitz E, Uckmann FP. Single access for minimally invasive aortic valve replacement Ann Thorac Surg 1997;64:120-123.[Abstract/Free Full Text]
- Pau KK, Yakub A, Awang Y. Minimally invasive aortic valve surgery: pocket AVR J Thorac Cardiovasc Surg 1998;115:255.[Free Full Text]
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Abstract
Introduction
