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Ann Thorac Surg 1999;68:863
© 1999 The Society of Thoracic Surgeons
a Dept of Thoracic and Cardiovascular Surgery, Jichi Medical School, Yakushiji 3311-1, Minami-Kawachi, Tochigi, Japan 329-0498
e-mail: tcvmisa{at}jichi.ac.jp
Invited commentary
Mediastinitis after cardiac surgery is a serious and potentially lethal complication. Bacterial culture from mediastinal fluid or tissues is essential for a definite, accurate diagnosis of mediastinitis, and it is of great importance to the cardiovascular surgeon to diagnose mediastinitis as soon as possible before signs and symptoms appear. Awareness of clinical signs and symptoms is necessary for diagnosis, and radiographic examination including computed tomography (CT) can provide helpful information. However, no specific chest CT findings for poststernotomy mediastinitis have yet been described. In addition, chest CT at the early stage of mediastinitis is of limited utility. Thus, we evaluated subcutaneous and mediastinal masses, mediastinal soft tissue swelling, sternal splitting [1], and pleural effusion on mediastinum window scans with respect to mediastinitis. Analyzing these multiple factors led us to the conclusion that the mediastinal soft tissue mass combined with bilateral pleural effusion can be a characteristic CT finding in poststernotomy infectious mediastinitis [2]. These changes are not characteristic features of the mediastinitis itself but are features of secondary reactions to it. The differences we observed in these changes between patients with and without mediastinitis were statistically significant.
Bitkover and colleagues have shown serial CT features of the healing stages after median sternotomy, and they have also shown CT features of postoperative complications after median sternotomy, including mediastinitis. All CT features in their prospective study were shown based on bone window settings alone; those in their retrospective study were shown based on both bone and mediastinum window settings. Therefore, their findings of the healing stages among patients without complications were limited to those of the incised sternum. I agree with the authors that the sternal gap revealed radiographically is not always a cause of patient discomfort, and callus formation around the sternum is not visible up to 3 months after sternotomy. However, Bitkover and colleagues did not clarify the CT criterion for diagnosis of poststernotomy mediastinitis. I would like to know on what CT features the radiologists based their diagnosis of mediastinitis, and I wonder if they considered mediastinal mass/effusion and pleural effusion to reach their conclusions. CT in patients without postoperative complications can reveal mediastinal fluid accumulation, pleural effusion, and sternal pseudoarthrosis, as Bitkover and associates showed, although bone window CT scans yield limited information. Bitkover and associates’ study would be more interesting and even more useful with additional evaluation of serial CT findings for the mediastinum and thorax in uncomplicated patients. I hope for additional studies to provide valuable information for the diagnosis of poststernotomy mediastinitis.
References
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