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J Thorac Cardiovasc Surg 1995;110:1030-1036
© 1995 Mosby, Inc.

CARDIAC AND PULMONARY REPLACEMENT

SINGLE-STAGE TREATMENT OF STERNAL WOUND COMPLICATIONS IN HEART TRANSPLANT RECIPIENTS IN WHOM PECTORALIS MAJOR MYOCUTANEOUS ADVANCEMENT FLAPS WERE USED

Jeffrey A. Ascherman, MDa, Norman E. Hugo, MDa, Mark R. Sultan, MDa, Michael C. Patsis, MDa, Craig R. Smith, MDb, Eric A. Rose, MDb


New York, N.Y.

Received for publication April 4, 1994. Accepted for publication Dec. 29, 1994. Address for reprints: Norman E. Hugo, MD, Division of Plastic Surgery, PH12-126, Columbia-Presbyterian Medical Center, 622 W. 168 th St., New York, NY 10032.

Abstract

Treatment of sternal wound complications is controversial, particularly in immunosuppressed heart transplant recipients. Regardless of the severity of infection, we combine immediate, aggressive débridement with bilateral pectoralis major myocutaneous advancement flaps in a single procedure. Compared with management with pectoralis major turnover flaps or distant pedicled muscle flaps, treatment of these sternal wounds with pectoralis major myocutaneous advancement flaps is simpler and quicker and provides better aesthetic results. Furthermore, because pectoralis major myocutaneous flaps are based on the thoracoacromial arteries, whether or not the internal mammary arteries have previously been harvested for coronary grafts is irrelevant. Twenty consecutive heart transplant recipients with sternal wound complications were treated with this technique. No intraoperative or perioperative deaths occurred. The morbidity rate was 30%, with seroma treated by needle aspiration in four patients (20%) being the most common complication. Only one patient had a postoperative wound infection. All patients had excellent functional and aesthetic results. (J THORACCARDIOVASCSURG1995;110:1030-6)

Sternal wound complications after median sternotomy are a significant problem, particularly in immunosuppressed heart transplant recipients. Reported mediastinal and sternal infection rates after cardiac surgery range from 0.4% to 5.1%. Go Go 1-7 Unilateral or bilateral internal mammary artery grafts, diabetes, and immunosuppression may all predispose a patient to these infections. Go Go 5,8 Subsequent sepsis or infectious spread to prosthetic valves, grafts, or suture lines, can be life-threatening.

A variety of early treatments have been proposed for sternal woundinfections, including delayed closure, closed catheter irrigation, Go 9 and omental flaps to the mediastinum. Go 10 Débridement followed by closure with muscle or myocutaneous flaps has been advocated more recently. Go Go 11-24 The pectoralis major, rectus abdominis, and latissimus dorsi muscles have all been used for this purpose. The pectoralis major is used most commonly. Sometimes it is isolated on internal mammary artery perforators and used as a turnover flap. Go Go 4,22 Others use it as an advancement flap based on the thoracoacromial artery. Go 20 By a separate lateral incision, the muscle may be divided from its humeral attachment to aid advancement. A rectus abdominis muscle flap may be included to cover the inferior segment of the wound. Go 4

We treat sternal wound complications with aggressive débridement and simultaneous closure using bilateral pectoralis major myocutaneous (PMM) advancement flaps. In this report, we describe our experience with this single-stage procedure in heart transplant recipients.

PATIENTS AND METHODS

Twenty consecutive sternal wound complications in heart transplant recipients were managed with PMM advancement flaps at the Columbia-Presbyterian Medical Center between January 1986 and June 1992. This represents 4.2% of the 477 heart transplantations (459 first-time transplantations, 18 repeated transplantations) performed at our institution during this period. Indications for treatment with PMM advancement flaps are listed in GoTable I. Culture-positive deep wound infections (13/20, 65%) were the most common indication for treatment. Several patients (4/20, 20%) had a culture-negative dehiscence or culture-negative drainage, but clinically their courses were consistent with sternal wound infection. Combining these 4 with the 13 culture-positive infections, our institution's overall sternal wound infection rate after heart transplantation was 3.6%. The remaining 3 patients (15%) did not have wound infections but underwent the procedure to obtain a delayed primary closure of their median sternotomy wound. Definitive closure at the time of transplantation had been precluded by hemodynamic instability. After stability was achieved, these patients returned to the operating room for closure with PMM advancement flaps rather than with sternal wiring.


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  		Table I. Indications for operation
 
Of the 13 culture-positive wound infections, more than half involved Staphylococcus aureus (GoTable II). Seven (7/13, 54%) of the infections were caused by this organism alone, and another (1/13, 8%) involved Staphylococcus aureus and Streptococcus group D.


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  		Table II. Microbiology of culture-positive wound infections
 
In the 17 patients with documented or suspected sternal wound infections (13 with cultures positive for bacteria, 4 with a culture-negative dehiscence or culture-negative drainage), the median number of days between heart transplantation and reoperation for PMM flap closure was 17, with a range of 4 days to 4 months. More specifically, among these 17 patients the time from transplantation to flap closure (GoTable III) was 1 week or less in 3 patients (18%), between 1 and 4 weeks in 9 patients (53%), and more than 4 weeks in 5 patients (29%).


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  		Table III. Operative timing of 17 infected sternotomy wounds
 
All 20 patients underwent treatment with PMM advancement flaps. In patients with evidence of a deep sternal wound infection, we operate immediately. The procedure is begun by fully reopening the original median sternotomy incision. All sternal wires are removed. In patients with suspected or culture-proven infections, the sternum is débrided back to bleeding bone. Mediastinal fluid and sternal bone are cultured.

PMM flaps are raised from medial to lateral in the relatively avascular plane beneath the pectoralis major muscles. This dissection is rapid and relatively bloodless. Superiorly, the dissection is stopped at the level of the clavicles. Laterally, the PMM flaps are raised as far as the anterior axillary line. The humeral insertion of the pectoralis major, the thoracoacromial vessels, and the pectoral nerves are all left intact. The pectoralis minor muscle is also left undisturbed. Inferiorly, the dissection passes below the superior fibers of the anterior rectus sheath but stays superficial to the actual rectus abdominis muscle (Figs. 1 and 2).



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  		Fig. 1. Elevation of myocutaneous flap in plane deep to pectoralis major muscle. Notice elevation of anterior rectus sheath, but not rectus abdominis muscle, in caudad portion of wound.

 


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  		Fig. 2. Intraoperative view of elevated PMM flap.

 
After these myocutaneous flaps have been raised bilaterally, the wound is flushed with 3 L of antibiotic solution with a pulse irrigator. A closed suction drain is placed under each flap, and a third drain is inserted in the mediastinum.

The flaps are then easily advanced to the midline. Although the underlying sternum is not rewired, there is minimal, if any, residual dead space. A strong, absorbable suture is used to appose the pectoralis major muscles and their overlying fascia. Inferiorly, the superior portion of the anterior rectus sheath is included in this deep layer of the closure. Skin is closed with either a running nylon suture or two layers of absorbable sutures (Fig. 3). Culture results determine the choice and duration of antibiotic therapy.



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  		Fig. 3. Cross-sectional view of closure over drains.

 
Survival analysis in this study was performed by the Kaplan-Meier product-limit estimate. Statistical significance between curves was examined with a log-rank test, with significance defined as a p value of less than 0.05.

RESULTS

Our average operative time for the procedure was 2 hours. The average estimated blood loss was 550 ml. Patients were usually extubated in the operating room, and postoperative admission to the intensive care unit was not always necessary. The mean number of postoperative days until the last drain was removed was 11, with a range of 3 to 21 days. Median length of hospitalization after flap closure was 28 days, with a range of 14 days to 10 months. (One patient's stay was prolonged to 10 months for reasons unrelated to the sternal wound infection.) The functional and aesthetic results of the procedure have been excellent. Shoulder mobility has not been affected by the operation. Chest wall contour is similar to that of patients who undergo uncomplicated median sternotomies (Fig. 4). With an average follow-up of 31/2 years and a maximum follow-up of 7 years, there have been no complaints of prolonged pain or of chest wall or sternal instability.



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  		Fig. 4. Normal chest contour in patient 6 weeks after treatment with PMM flaps.

 
There were no deaths in the intraoperative period or within 30 days after operation in our series. Six patients (30%) experienced postoperative morbidity (GoTable IV). The most common untoward sequela was seroma formation, which occurred in 4 (20%) patients. Each occurred after all drains had been removed and was managed by simple needle aspiration, either at the bedside or during outpatient visits.


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  		Table IV. Morbidity
 
Two patients had partial wound dehiscences, both of which were closed under sterile technique at the bedside. There were no complete dehiscences. One patient was taken back to the operating room from the recovery room to rule out a hematoma; marked muscle edema, rather than hematoma, was found. Another patient had a delayed hemorrhage, which was treated with bedside aspiration on postoperative day 32.

Only one patient had a postoperative wound infection. This patient did well initially and was discharged to his home 25 days after his PMM flap procedure. Because of continued serous wound drainage, however, he had a computed tomography chest scan 41/2 months after his flap procedure. This revealed a subpectoral collection that necessitated readmission. In the operating room, an abscess was drained, the surrounding necrotic tissue was débrided, and the PMM flaps were reapproximated. The patient subsequently did well and has had no evidence of recurrent infection for 2 years.

Examination of the Kaplan-Meier curves shows no statistically significant difference (p = 0.32) in survival between the 17 patients in this series with sternal wound infections and the 442 patients who received initial heart transplants at our institution during this same period and did not have sternal wound infections (Fig. 5).



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  		Fig. 5. Kaplan-Meier estimates for heart transplant recipients with sternal wound infections treated with PMM flaps and for all other patients undergoing an initial heart transplant during the same period at Columbia-Presbyterian Medical Center (January 1986 to June 1992; n = 459).

 
DISCUSSION

Median sternotomy has become the preferred incision for open cardiac procedures since its description by Julian and colleagues Go 25 in 1957. Complications associated with median sternotomy, such as infection, can be disastrous. Our institution's overall infection rate for median sternotomies is 1.3%, Go 23 well within the rates of 0.4% to 5.1% published in other series. Go Go 1-7 Not surprisingly, our sternal wound infection rate in immunosuppressed heart transplant recipients is higher—3.6%. This is comparable with the rate of 4.5% published by Hofflin and colleagues Go 26 in a series of 110 heart transplant recipients. When sternal infections do arise, particularly in heart transplant recipients, a rapid, effective treatment is required to avoid potentially life-threatening sequelae.

Some surgeons have advocated débridement and frequent packing changes, sometimes followed by a delayed closure, for these infections. However, this treatment may involve prolonged hospitalization. Furthermore, wound healing times of up to 16 months Go 27 and mortality rates as high as 46% Go 28 have been recorded with this treatment.

In 1963, operative débridement followed by sternal closure over irrigation catheters was reported. Go 9 This approach didshorten average hospitalization times, Go 7 but reoperation rates for persistent infection ranged from 13% to 66%. Go Go 29,30 Fatal superinfection and systemic toxicity caused by the irrigation solution were other problems reported with this treatment. Go 29

Many surgeons now transpose vascularized tissue into these relatively avascular wounds. In 1976, Lee, Schimert, and Shatkin Go 10 described the use of the greater omentum for this procedure in 3 patients. However, use of the omentum required an additional laparotomy. Other flaps have been advocated for treatment of sternal wound infections since then, including the rectus abdominis and pectoralis major flaps. Go Go Go 4,11-24 The effectiveness of muscle flaps in treating osteomyelitis has been demonstrated in studies by Mathes, Alpert, and Chang. Go 31 Use of the rectus abdominis flap entails a significant increase in the amount of dissection required and is sometimes followed by abdominal hernia formation. Even more important, this flap may be unavailable if the internal mammary arteries were either used for coronary artery bypass grafting or damaged by sternal wires.

The most frequently used flap today for treating sternal wound infections is the pectoralis major flap. Some surgeons use it as a turnover flap based on its medial blood supply. Go 22 However, this involves dividing the pectoralis major laterally and rotating the lateral portion of the muscle into the wound, a technique that leaves additional contour deformities and may require separate counterincisions. Furthermore, like the rectus abdominis flap, this turnover flap requires a patent internal mammary artery. It is therefore not an option in many patients.

In contrast to the aforementioned techniques, use of PMM advancement flaps does not require intact internal mammary arteries, involves no additional incisions, leaves no functional deficits, and produces excellent cosmetic results. We have also found simple advancement of the anterior rectus sheath to the midline to provide sufficient coverage inferiorly. Although some believe that our method does not adequately "fill" the mediastinal dead space, we have not found this to be a problem. The only recurrent infection in our series was a subpectoral collection detected 41/2 months after operation. In addition, as demonstrated by Kaplan-Meier survival analysis, heart transplant recipients treated for sternal wound infections with this technique have shown no decrease in long-term survival compared with patients without these infections.

We recommend this single-stage approach for the treatment of sternal wound complications in heart transplant recipients. In a separate study, weGo 23 also found this method extremely efficacious for management of sternal wound complications in patients not undergoing transplantation. We emphasize early, aggressive débridement of all necrotic bone and immediate coverage with PMM advancement flaps. This method is simple and effective and produces excellent functional and cosmetic results. The associated morbidity has been low, particularly considering how ill these immunocompromised patients are. Furthermore, in contrast to the rectus abdominis and pectoralis turnover flaps, PMM advancement flaps do not require intact internal mammary arteries.

Acknowledgments

We thank Alan Weinberg, MS, and Michael Sternberg, BS, for their help with the statistical analysis of our data.

Footnotes

From the Department of Surgery, Divisions of Plastic and Reconstructive Surgery a and Thoracic and Cardiac Surgery, b Columbia-Presbyterian Medical Center, New York, N.Y. Back

References

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