EComment. A new protective device for deep sternal wound infection

Abstract

We read with great interest the article by Thorsteinsson et al. [1], regarding the management of a life-threatening bleed from a disrupted right ventricle in the setting of anterior mediastinitis. Bleeding was controlled with a Teflon patch under cardiopulmonary bypass. Deep sternal wound infection after cardiac surgery is a dreaded complication and portends serious morbidity. Many surgical techniques are available for the management of this complication. In the last decade, negative-pressure therapy has been used with encouraging results and has emerged as a novel and efficacious strategy for managing patients with post-sternotomy mediastinitis [2,3]. Since adoption of this method of management and the endorsement of its routine use, many have reported a potentially devastating complication of right ventricle rupture [3,4]. Moreover, the US Food and Drug Administration has published a warning against the risk of major bleeding from the application of negative-pressure therapy to the mediastinum. A plethora of techniques to prevent the disruption of the right ventricle during vacuum-assisted therapy has been successful; namely, the release of adhesions between the deeper aspect of the sternum and the right ventricle on initial debridement and wire removal, avoidance of any sharp sternal edges and use of paraffin gauzes between the foam and the right ventricle. Despite the application of the above-mentioned technical modifications for protecting the heart, dreadful right ventricle ruptures still occur. Ingemansson et al. [5] recently published a series of six patients with deep sternal wound infections managed with a new protective devise. A semi-rigid plastic rectangular device with a foam pocket fitted base is inserted between the sternal halves. The foam is separated from the anterior aspect of the heart by two layers of Delnet (Delstar Technologies, Inc, Middletown, DE, USA). A second foam is then placed under the base of the device to stabilize the sternal edges. This device proves to be of tremendous benefit. However, further refinement and development of user-friendly devices will permit the treatment of deep sternal wound infection while attenuating the risk of heart rupture. Conflict of interest: none declared.