Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery

Abstract

Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.