Major Bleeding Events in Patients with Vacuum-Assisted Therapy of Post-Sternotomy Mediastinits

Abstract

Objective: In the last decade vacuum assisted therapy for surgical treatment of post-sternotomy mediastinitis became standard therapy. Severe complications like acute major bleeding are rare, but can be lethal. Methods: Between January 2011 and July 2014 68 (1.4%) of 4865 patients (pts.) with sternotomy received a vacuum assisted closure (VAC) due to post-sternotomy mediastinitis in our department. We analyzed patient characteristics and clinical outcome retrospectively. Results: The mean age of patients with mediastinitis was 67.6 ± 11.7 years. 38% (26 pts.) were female. 53% (36 pts.) underwent coronary artery bypass grafting with use of bilateral internal mammary arteries in 38% (26 pts.). 15% (10 pts.) had isolated aortic valve replacement, 29% (20 pts.) other combined procedures and 2% (2 pt.) ventricular assist devices. Body-mass-index was 28.5 ± 5.1 kg/m2. Diagnosis of deep sternal infection occurred 21.8 ± 18.3 days after primary operation. Infection related mean hospital stay was 22 ± 11.7 days with 8 ± 4.2 VAC-operations and mean weight loss of 4.8 ± 5.3 kg. Total in-hospital mortality was 17.6% (12 pts.). 10 pts. died due to sepsis and multiple organ failure (7 pts.), heart failure (2 pats.) or endocarditis. Major bleeding complication occurred in 4 pts. (6.9%) due to injury of right ventricle in 3 pts. and massive erosion of the right lung in one patient. Emergency extracorporal circulation (ECC) via femoral vessels was established in all cases, nevertheless one patient died within the operation. Sternum restabilization was performed in three patients during emergency operation. One patient died subsequently at day 18 due to sepsis. Two of these patients are still alive. One patient was re-admitted with recurrent sternum instability after 15 days. Conclusion: Major bleeding events due to injury of the right ventricle are a rare, but potentially lethal complication of post-sternotomy mediastinitis. However, VAC therapy is an effective method, but surgical debridement and refixation of the sternum should performed as early as possible.